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HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 401k Plan overview

Plan NameHOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN
Plan identification number 501

HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance

401k Sponsoring company profile

HOLSUM, INC has sponsored the creation of one or more 401k plans.

Company Name:HOLSUM, INC
Employer identification number (EIN):850164944
NAIC Classification:211120
NAIC Description:Crude Petroleum Extraction

Additional information about HOLSUM, INC

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2013-09-30
Company Identification Number: 0801859963
Legal Registered Office Address: PO BOX 2527

ROSWELL
United States of America (USA)
88202

More information about HOLSUM, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-09-01
5012021-09-01
5012020-09-01
5012019-09-01
5012018-09-01
5012017-09-01
5012016-09-01
5012015-09-01MR. ANDREW TEOH
5012014-09-01MR. ANDREW TEOH
5012013-09-01MR. MARC REISCHMAN
5012012-09-01MARC REISCHMAN
5012011-09-01MARC REISCHMAN
5012010-09-01MARC REISCHMAN MARC REISCHMAN2012-08-07
5012009-09-01MARC REISCHMAN MARC REISCHMAN2011-10-18

Plan Statistics for HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN

401k plan membership statisitcs for HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN

Measure Date Value
2022: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-09-0195
Total number of active participants reported on line 7a of the Form 55002022-09-0194
Total of all active and inactive participants2022-09-0194
Total participants2022-09-0194
2021: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-01126
Total number of active participants reported on line 7a of the Form 55002021-09-0193
Total of all active and inactive participants2021-09-0193
Total participants2021-09-0193
2020: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01132
Total number of active participants reported on line 7a of the Form 55002020-09-01127
Total of all active and inactive participants2020-09-01127
Total participants2020-09-01127
2019: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01120
Total number of active participants reported on line 7a of the Form 55002019-09-01132
Total of all active and inactive participants2019-09-01132
2018: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01109
Total number of active participants reported on line 7a of the Form 55002018-09-01111
Total of all active and inactive participants2018-09-01111
Total participants2018-09-01111
2017: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01114
Total number of active participants reported on line 7a of the Form 55002017-09-01109
Total of all active and inactive participants2017-09-01109
Total participants2017-09-01109
2016: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01111
Total number of active participants reported on line 7a of the Form 55002016-09-01114
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01114
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2016-09-010
Total participants2016-09-01114
2015: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01102
Total number of active participants reported on line 7a of the Form 55002015-09-01111
Number of retired or separated participants receiving benefits2015-09-010
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01111
2014: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-0187
Total number of active participants reported on line 7a of the Form 55002014-09-01102
Number of retired or separated participants receiving benefits2014-09-010
Number of other retired or separated participants entitled to future benefits2014-09-010
Total of all active and inactive participants2014-09-01102
2013: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-09-01104
Total number of active participants reported on line 7a of the Form 55002013-09-0187
Total of all active and inactive participants2013-09-0187
2012: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-09-0192
Total number of active participants reported on line 7a of the Form 55002012-09-01104
Total of all active and inactive participants2012-09-01104
2011: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-09-0198
Total number of active participants reported on line 7a of the Form 55002011-09-0192
Total of all active and inactive participants2011-09-0192
2010: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year2010-09-0174
Total number of active participants reported on line 7a of the Form 55002010-09-0198
Total of all active and inactive participants2010-09-0198
2009: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-09-01104
Total number of active participants reported on line 7a of the Form 55002009-09-0174
Total of all active and inactive participants2009-09-0174

Financial Data on HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN

Measure Date Value
2016 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2016 401k financial data
Total income from all sources2016-08-31$0
Total plan assets at end of year2016-08-31$0
Total plan assets at beginning of year2016-08-31$0
Net plan assets at end of year (total assets less liabilities)2016-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2016-08-31$0
2015 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2015 401k financial data
Total income from all sources2015-08-31$0
Total plan assets at end of year2015-08-31$0
Total plan assets at beginning of year2015-08-31$0
Net plan assets at end of year (total assets less liabilities)2015-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2015-08-31$0
2014 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2014 401k financial data
Total income from all sources2014-08-31$0
Total plan assets at end of year2014-08-31$0
Total plan assets at beginning of year2014-08-31$0
Net plan assets at end of year (total assets less liabilities)2014-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2014-08-31$0
2013 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2013 401k financial data
Total income from all sources2013-08-31$0
Total plan assets at end of year2013-08-31$0
Total plan assets at beginning of year2013-08-31$0
Net plan assets at end of year (total assets less liabilities)2013-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2013-08-31$0
2012 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2012 401k financial data
Total income from all sources2012-08-31$0
Total plan assets at end of year2012-08-31$0
Total plan assets at beginning of year2012-08-31$0
Net plan assets at end of year (total assets less liabilities)2012-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2012-08-31$0
2011 : HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2011 401k financial data
Total plan assets at end of year2011-08-31$0
Net plan assets at end of year (total assets less liabilities)2011-08-31$0
Net plan assets at beginning of year (total assets less liabilities)2011-08-31$0

Form 5500 Responses for HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN

2022: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-09-01Type of plan entitySingle employer plan
2022-09-01Submission has been amendedNo
2022-09-01This submission is the final filingNo
2022-09-01This return/report is a short plan year return/report (less than 12 months)No
2022-09-01Plan is a collectively bargained planNo
2022-09-01Plan funding arrangement – General assets of the sponsorYes
2022-09-01Plan benefit arrangement – InsuranceYes
2022-09-01Plan benefit arrangement – General assets of the sponsorYes
2021: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-09-01Type of plan entityMulitple employer plan
2021-09-01Submission has been amendedNo
2021-09-01This submission is the final filingNo
2021-09-01This return/report is a short plan year return/report (less than 12 months)No
2021-09-01Plan is a collectively bargained planNo
2021-09-01Plan funding arrangement – General assets of the sponsorYes
2021-09-01Plan benefit arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – General assets of the sponsorYes
2020: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-09-01Type of plan entityMulitple employer plan
2020-09-01Submission has been amendedNo
2020-09-01This submission is the final filingNo
2020-09-01This return/report is a short plan year return/report (less than 12 months)No
2020-09-01Plan is a collectively bargained planNo
2020-09-01Plan funding arrangement – General assets of the sponsorYes
2020-09-01Plan benefit arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – General assets of the sponsorYes
2019: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-09-01Type of plan entityMulitple employer plan
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2018: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – InsuranceYes
2017: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – InsuranceYes
2016: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – InsuranceYes
2015: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – InsuranceYes
2014: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-09-01Type of plan entitySingle employer plan
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – InsuranceYes
2013: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-09-01Type of plan entitySingle employer plan
2013-09-01Plan funding arrangement – InsuranceYes
2013-09-01Plan benefit arrangement – InsuranceYes
2012: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-09-01Type of plan entitySingle employer plan
2012-09-01Plan funding arrangement – InsuranceYes
2012-09-01Plan benefit arrangement – InsuranceYes
2011: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-09-01Type of plan entitySingle employer plan
2011-09-01Plan funding arrangement – InsuranceYes
2011-09-01Plan benefit arrangement – InsuranceYes
2010: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2010 form 5500 responses
2010-09-01Type of plan entitySingle employer plan
2010-09-01Plan funding arrangement – InsuranceYes
2010-09-01Plan benefit arrangement – InsuranceYes
2009: HOLSUM, INC. EMPLOYEES HEALTH & WELFARE PLAN 2009 form 5500 responses
2009-09-01Type of plan entitySingle employer plan
2009-09-01Plan funding arrangement – InsuranceYes
2009-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2281
Policy instance 5
Insurance contract or identification numberWI2281
Number of Individuals Covered126
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $28,077
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $471,350
Commission paid to Insurance BrokerUSD $28,077
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2281
Policy instance 4
Insurance contract or identification numberWI2281
Number of Individuals Covered126
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,743
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGFZ41H25
Policy instance 3
Insurance contract or identification numberGFZ41H25
Number of Individuals Covered4
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $772
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberCM10001222-0000
Policy instance 2
Insurance contract or identification numberCM10001222-0000
Number of Individuals Covered99
Insurance policy start date2021-12-01
Insurance policy end date2022-11-01
Total amount of commissions paid to insurance brokerUSD $458
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,340
Commission paid to Insurance BrokerUSD $458
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract number669688
Policy instance 1
Insurance contract or identification number669688
Number of Individuals Covered8
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $65,051
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract number669688
Policy instance 1
Insurance contract or identification number669688
Number of Individuals Covered6
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,510
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number167608
Policy instance 2
Insurance contract or identification number167608
Number of Individuals Covered127
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $397
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,028
Commission paid to Insurance BrokerUSD $397
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGFZ41H25
Policy instance 3
Insurance contract or identification numberGFZ41H25
Number of Individuals Covered3
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $532
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2281
Policy instance 4
Insurance contract or identification numberWI2281
Number of Individuals Covered144
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,039
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2281
Policy instance 5
Insurance contract or identification numberWI2281
Number of Individuals Covered145
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $31,936
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $547,001
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2281
Policy instance 4
Insurance contract or identification numberWI2281
Number of Individuals Covered158
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $24,120
Total amount of fees paid to insurance companyUSD $5,000
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $579,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,120
Amount paid for insurance broker fees5000
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGFZ41H25
Policy instance 3
Insurance contract or identification numberGFZ41H25
Number of Individuals Covered3
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number167608
Policy instance 2
Insurance contract or identification number167608
Number of Individuals Covered124
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $398
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $398
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract number669688
Policy instance 1
Insurance contract or identification number669688
Number of Individuals Covered6
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,938,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGFZ41H25
Policy instance 5
Insurance contract or identification numberGFZ41H25
Number of Individuals Covered3
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number10011132
Policy instance 4
Insurance contract or identification number10011132
Number of Individuals Covered133
Insurance policy start date2019-01-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $17,771
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,771
Insurance broker organization code?3
WPS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 10159 )
Policy contract number10011132
Policy instance 3
Insurance contract or identification number10011132
Number of Individuals Covered24
Insurance policy start date2019-01-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $2,796
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,796
Insurance broker organization code?3
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number167608
Policy instance 2
Insurance contract or identification number167608
Number of Individuals Covered117
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $373
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $373
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract number669688
Policy instance 1
Insurance contract or identification number669688
Number of Individuals Covered6
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number10011132
Policy instance 1
Insurance contract or identification number10011132
Number of Individuals Covered83
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $381
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees381
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number167608
Policy instance 3
Insurance contract or identification number167608
Number of Individuals Covered107
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $349
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees349
EMPLOYEE BENEFITS CORPORATION (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberH19573
Policy instance 4
Insurance contract or identification numberH19573
Number of Individuals Covered104
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of fees paid to insurance companyUSD $5,747
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHRA
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WPS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 10159 )
Policy contract number10011132
Policy instance 2
Insurance contract or identification number10011132
Number of Individuals Covered25
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WPS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 10159 )
Policy contract number10011132
Policy instance 2
Insurance contract or identification number10011132
Number of Individuals Covered53
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NETWORK HEALTH INC (National Association of Insurance Commissioners NAIC id number: 95737 )
Policy contract number101123
Policy instance 1
Insurance contract or identification number101123
Number of Individuals Covered93
Insurance policy start date2017-01-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $188,200
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number167608
Policy instance 5
Insurance contract or identification number167608
Number of Individuals Covered105
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $334
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EMPLOYEE BENEFITS CORPORATION (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberH19573
Policy instance 6
Insurance contract or identification numberH19573
Number of Individuals Covered96
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $4,987
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHRA
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number10011132
Policy instance 3
Insurance contract or identification number10011132
Number of Individuals Covered46
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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