CAR-GRAPH INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN
| Measure | Date | Value |
|---|
| 2022: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 80 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 80 |
| Number of employers contributing to the scheme | 2022-06-01 | 0 |
| 2020: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 89 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
| Total of all active and inactive participants | 2020-06-01 | 89 |
| Number of employers contributing to the scheme | 2020-06-01 | 0 |
| 2019: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 105 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
| Total of all active and inactive participants | 2019-06-01 | 105 |
| 2018: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 101 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 102 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 102 |
| 2017: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 95 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 95 |
| 2016: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 114 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
| Total of all active and inactive participants | 2016-06-01 | 115 |
| 2015: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 88 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 93 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 1 |
| Total of all active and inactive participants | 2015-06-01 | 94 |
| 2014: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 114 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 114 |
| 2013: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 114 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 114 |
| 2011: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 96 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 98 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 0 |
| Total of all active and inactive participants | 2011-06-01 | 98 |
| 2010: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-06-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 98 |
| Number of retired or separated participants receiving benefits | 2010-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-06-01 | 0 |
| Total of all active and inactive participants | 2010-06-01 | 98 |
| 2009: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-06-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 124 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 0 |
| Total of all active and inactive participants | 2009-06-01 | 124 |
| 2022: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Submission has been amended | No |
| 2019-06-01 | This submission is the final filing | No |
| 2019-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-06-01 | Plan is a collectively bargained plan | No |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Submission has been amended | No |
| 2018-06-01 | This submission is the final filing | No |
| 2018-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-06-01 | Plan is a collectively bargained plan | No |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | Submission has been amended | No |
| 2017-06-01 | This submission is the final filing | No |
| 2017-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-06-01 | Plan is a collectively bargained plan | No |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | Submission has been amended | No |
| 2011-06-01 | This submission is the final filing | No |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-06-01 | Plan is a collectively bargained plan | No |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2010 form 5500 responses |
|---|
| 2010-06-01 | Type of plan entity | Single employer plan |
| 2010-06-01 | Submission has been amended | No |
| 2010-06-01 | This submission is the final filing | No |
| 2010-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-06-01 | Plan is a collectively bargained plan | No |
| 2010-06-01 | Plan funding arrangement – Insurance | Yes |
| 2010-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: CAR-GRAPH INC FLEXIBLE COMPENSATION PLAN 2009 form 5500 responses |
|---|
| 2009-06-01 | Type of plan entity | Single employer plan |
| 2009-06-01 | Submission has been amended | No |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-06-01 | Plan is a collectively bargained plan | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 009925 |
| Policy instance | 3 |
| Insurance contract or identification number | 009925 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $893 | | Total amount of fees paid to insurance company | USD $298 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $893 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SERVICE FEE |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 2 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $84 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 34735 |
| Policy instance | 1 |
| Insurance contract or identification number | 34735 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $49,496 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,062,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,047 | | 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 | 5944512 |
| Policy instance | 1 |
| Insurance contract or identification number | 5944512 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,115 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,115 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908806 |
| Policy instance | 2 |
| Insurance contract or identification number | 908806 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,172 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,172 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 34735 |
| Policy instance | 3 |
| Insurance contract or identification number | 34735 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $59,118 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,176,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,118 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 4 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $105 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $105 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908806 |
| Policy instance | 2 |
| Insurance contract or identification number | 908806 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,150 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,150 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5944512 |
| Policy instance | 1 |
| Insurance contract or identification number | 5944512 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,282 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,282 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 034735 |
| Policy instance | 3 |
| Insurance contract or identification number | 034735 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $72,139 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,079,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,139 | | Insurance broker organization code? | 3 |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 4 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $104 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $104 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5944512 |
| Policy instance | 1 |
| Insurance contract or identification number | 5944512 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $919 | | Total amount of fees paid to insurance company | USD $91 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $919 | | Amount paid for insurance broker fees | 91 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 908806 |
| Policy instance | 2 |
| Insurance contract or identification number | 908806 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $1,366 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,366 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 34735 |
| Policy instance | 3 |
| Insurance contract or identification number | 34735 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $63,435 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,259,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $63,435 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 34735 |
| Policy instance | 3 |
| Insurance contract or identification number | 34735 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $65,752 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,096,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,752 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05944512 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05944512 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $1,031 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,031 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR AND ASSOCIATES INC. |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | 5471566 |
| Policy instance | 2 |
| Insurance contract or identification number | 5471566 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $1,192 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,133 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,192 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC. |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | 5471566 |
| Policy instance | 4 |
| Insurance contract or identification number | 5471566 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $876 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $12,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $876 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF ARIZONA INC |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 3 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $92 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $92 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF ARIZONA |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3329432 |
| Policy instance | 2 |
| Insurance contract or identification number | 3329432 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $48,373 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,221,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 48373 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600410 |
| Policy instance | 1 |
| Insurance contract or identification number | SGM600410 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $550 | | Total amount of fees paid to insurance company | USD $23 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 Carrier | USD $3,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $550 | | Amount paid for insurance broker fees | 23 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | AO12 |
| Policy instance | 1 |
| Insurance contract or identification number | AO12 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $68 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $965 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS CORROON CORP OF AZ |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600410 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM600410 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $428 | | Total amount of fees paid to insurance company | USD $12 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 Carrier | USD $2,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $428 | | Amount paid for insurance broker fees | 12 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | 5471566 |
| Policy instance | 5 |
| Insurance contract or identification number | 5471566 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $785 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $11,218 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $785 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF ARIZONA INC |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 2 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $86 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $86 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF ARIZONA |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3329432 |
| Policy instance | 3 |
| Insurance contract or identification number | 3329432 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $47,417 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $948,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 47417 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | AO12 |
| Policy instance | 1 |
| Insurance contract or identification number | AO12 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $838 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $11,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $838 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS CORROON CORP OF AZ |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 2 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $96 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $96 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF ARIZONA |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3329432 |
| Policy instance | 3 |
| Insurance contract or identification number | 3329432 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $48,980 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $978,021 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 48980 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR PAYMENTS GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600410 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM600410 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $484 | | Total amount of fees paid to insurance company | USD $1 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 Carrier | USD $3,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $484 | | Amount paid for insurance broker fees | 1 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF AZ |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 4 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $102 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $1,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3329432 |
| Policy instance | 3 |
| Insurance contract or identification number | 3329432 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $63,086 | | Total amount of fees paid to insurance company | USD $244 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,051,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | AO12 |
| Policy instance | 1 |
| Insurance contract or identification number | AO12 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $881 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $12,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600410 |
| Policy instance | 2 |
| Insurance contract or identification number | SGM600410 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $737 | | Total amount of fees paid to insurance company | USD $42 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 Carrier | USD $4,911 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3329432 |
| Policy instance | 3 |
| Insurance contract or identification number | 3329432 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $57,591 | | Total amount of fees paid to insurance company | USD $222 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $959,853 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
| Policy contract number | AO12 |
| Policy instance | 1 |
| Insurance contract or identification number | AO12 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $896 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $12,804 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 27450 |
| Policy instance | 4 |
| Insurance contract or identification number | 27450 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $97 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 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 | | 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 Carrier | USD $970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600410 |
| Policy instance | 2 |
| Insurance contract or identification number | SGM600410 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $590 | | Total amount of fees paid to insurance company | USD $32 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 Carrier | USD $3,861 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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