THE ARIZONA HUMANE SOCIETY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 277 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 300 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 3 |
| Total of all active and inactive participants | 2022-01-01 | 304 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 258 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 282 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 285 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 254 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 246 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 249 |
| Number of employers contributing to the scheme | 2020-12-01 | 0 |
| 2019: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 250 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 250 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 252 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2018: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 252 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 256 |
| 2017: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 245 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 250 |
| Total participants, beginning-of-year | 2017-11-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-11-01 | 217 |
| Number of retired or separated participants receiving benefits | 2017-11-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2017-11-01 | 0 |
| Total of all active and inactive participants | 2017-11-01 | 222 |
| 2016: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-11-01 | 228 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-11-01 | 231 |
| Number of retired or separated participants receiving benefits | 2016-11-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2016-11-01 | 0 |
| Total of all active and inactive participants | 2016-11-01 | 237 |
| 2015: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-11-01 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-11-01 | 227 |
| Number of retired or separated participants receiving benefits | 2015-11-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-11-01 | 0 |
| Total of all active and inactive participants | 2015-11-01 | 229 |
| 2014: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-11-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 197 |
| Number of retired or separated participants receiving benefits | 2014-11-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-11-01 | 0 |
| Total of all active and inactive participants | 2014-11-01 | 198 |
| 2013: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 195 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2013-11-01 | 0 |
| Total of all active and inactive participants | 2013-11-01 | 196 |
| 2012: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 185 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 0 |
| Total of all active and inactive participants | 2012-11-01 | 187 |
| 2011: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 164 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 0 |
| Total of all active and inactive participants | 2011-11-01 | 167 |
| 2009: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 132 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 127 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 0 |
| Total of all active and inactive participants | 2009-11-01 | 131 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-11-01 | 0 |
| 2022: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Submission has been amended | No |
| 2017-12-01 | This submission is the final filing | No |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-12-01 | Plan is a collectively bargained plan | No |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017-11-01 | Type of plan entity | Single employer plan |
| 2017-11-01 | Submission has been amended | No |
| 2017-11-01 | This submission is the final filing | No |
| 2017-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-11-01 | Plan is a collectively bargained plan | No |
| 2017-11-01 | Plan funding arrangement – Insurance | Yes |
| 2017-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-11-01 | Type of plan entity | Single employer plan |
| 2016-11-01 | Submission has been amended | No |
| 2016-11-01 | This submission is the final filing | No |
| 2016-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-11-01 | Plan is a collectively bargained plan | No |
| 2016-11-01 | Plan funding arrangement – Insurance | Yes |
| 2016-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-11-01 | Type of plan entity | Single employer plan |
| 2015-11-01 | Submission has been amended | No |
| 2015-11-01 | This submission is the final filing | No |
| 2015-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-11-01 | Plan is a collectively bargained plan | No |
| 2015-11-01 | Plan funding arrangement – Insurance | Yes |
| 2015-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-11-01 | Type of plan entity | Single employer plan |
| 2014-11-01 | Submission has been amended | No |
| 2014-11-01 | This submission is the final filing | No |
| 2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-11-01 | Plan is a collectively bargained plan | No |
| 2014-11-01 | Plan funding arrangement – Insurance | Yes |
| 2014-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Submission has been amended | No |
| 2013-11-01 | This submission is the final filing | No |
| 2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-11-01 | Plan is a collectively bargained plan | No |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ARIZONA HUMANE SOCIETY WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | Yes |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10190781001 |
| Policy instance | 3 |
| Insurance contract or identification number | 10190781001 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,028 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $19,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,028 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70003 |
| Policy instance | 2 |
| Insurance contract or identification number | 70003 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $28,924 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $186,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,924 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5955035 |
| Policy instance | 1 |
| Insurance contract or identification number | 5955035 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,820 | | Total amount of fees paid to insurance company | USD $131 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $89,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,820 | | Amount paid for insurance broker fees | 131 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10190781001 |
| Policy instance | 3 |
| Insurance contract or identification number | 10190781001 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,644 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,644 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5955035 |
| Policy instance | 1 |
| Insurance contract or identification number | 5955035 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,076 | | Total amount of fees paid to insurance company | USD $744 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,826 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,076 | | Amount paid for insurance broker fees | 744 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70003 |
| Policy instance | 2 |
| Insurance contract or identification number | 70003 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $24,415 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $158,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,415 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5955035 |
| Policy instance | 2 |
| Insurance contract or identification number | 5955035 | | Number of Individuals Covered | 317 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $587 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $587 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10190781001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10190781001 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $122 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $122 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70003 |
| Policy instance | 3 |
| Insurance contract or identification number | 70003 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,952 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $12,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,952 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 70003 |
| Policy instance | 3 |
| Insurance contract or identification number | 70003 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $27,228 | | Total amount of fees paid to insurance company | USD $6,666 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $152,985 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,228 | | Amount paid for insurance broker fees | 6666 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5955035 |
| Policy instance | 2 |
| Insurance contract or identification number | 5955035 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $6,637 | | Total amount of fees paid to insurance company | USD $1,853 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,637 | | Amount paid for insurance broker fees | 1853 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10190781001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10190781001 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,350 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,690 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,350 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466592 |
| Policy instance | 5 |
| Insurance contract or identification number | 466592 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $17,993 | | Total amount of fees paid to insurance company | USD $900 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $102,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,993 | | Amount paid for insurance broker fees | 900 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0007327747 |
| Policy instance | 4 |
| Insurance contract or identification number | 0007327747 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $10 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 140605 |
| Policy instance | 3 |
| Insurance contract or identification number | 140605 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $2,863 | | Total amount of fees paid to insurance company | USD $143 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,863 | | Amount paid for insurance broker fees | 143 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5955035 |
| Policy instance | 2 |
| Insurance contract or identification number | 5955035 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $5,811 | | Total amount of fees paid to insurance company | USD $769 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,811 | | Amount paid for insurance broker fees | 769 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10190781001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10190781001 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,098 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,098 | | Insurance broker organization code? | 3 |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0299057 |
| Policy instance | 6 |
| Insurance contract or identification number | R0299057 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $85 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $16,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $85 | | Insurance broker organization code? | 3 |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0299057 |
| Policy instance | 5 |
| Insurance contract or identification number | R0299057 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $67 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $1,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466592 |
| Policy instance | 4 |
| Insurance contract or identification number | 466592 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $16,433 | | Total amount of fees paid to insurance company | USD $904 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $118,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0007327747 |
| Policy instance | 3 |
| Insurance contract or identification number | 0007327747 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $51 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 ) |
| Policy contract number | 11000-2012 |
| Policy instance | 1 |
| Insurance contract or identification number | 11000-2012 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $5,140 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 140605 |
| Policy instance | 2 |
| Insurance contract or identification number | 140605 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $3,100 | | Total amount of fees paid to insurance company | USD $171 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 ) |
| Policy contract number | 11000-2012 |
| Policy instance | 4 |
| Insurance contract or identification number | 11000-2012 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $130 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $130 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 466592 |
| Policy instance | 3 |
| Insurance contract or identification number | 466592 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 903031 |
| Policy instance | 2 |
| Insurance contract or identification number | 903031 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,523 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0903051 |
| Policy instance | 1 |
| Insurance contract or identification number | 0903051 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,086 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5086 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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