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LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 401k Plan overview

Plan NameLA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE
Plan identification number 502

LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

LA PAZ REGIONAL HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name:LA PAZ REGIONAL HOSPITAL
Employer identification number (EIN):860260959
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022019-07-01
5022018-06-01
5022018-06-01
5022018-06-01REGINA MARTINEZ2021-04-01 KEVIN M. BROWN2021-04-01
5022017-06-30REGINA MARTINEZ
5022016-06-01REGINA MARTINEZ
5022016-06-01
5022016-06-01
5022015-06-01REGINA MARTINEZ
5022015-06-01REGINA MARTINEZ
5022014-07-01REGINA MARTINEZ
5022013-07-01REGINA MARTINEZ
5022012-07-01REGINA MARTINEZ
5022011-07-01REGINA MARTINEZ
5022010-06-01REGINA MARTINEZ
5022009-06-01REGINA MARTINEZ

Plan Statistics for LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE

401k plan membership statisitcs for LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE

Measure Date Value
2022: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2022 401k membership
Total participants, beginning-of-year2022-01-01166
Total number of active participants reported on line 7a of the Form 55002022-01-01166
Total of all active and inactive participants2022-01-01166
Total participants2022-01-01166
2019: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2019 401k membership
Total participants, beginning-of-year2019-07-01174
Total number of active participants reported on line 7a of the Form 55002019-07-01174
Total of all active and inactive participants2019-07-01174
Total participants2019-07-01174
2018: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2018 401k membership
Total participants, beginning-of-year2018-06-01176
Total number of active participants reported on line 7a of the Form 55002018-06-01176
Total of all active and inactive participants2018-06-01176
Total participants2018-06-01176
Number of participants with account balances2018-06-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2018-06-010
Number of employers contributing to the scheme2018-06-010
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
2017: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2017 401k membership
Total participants, beginning-of-year2017-06-30204
Total number of active participants reported on line 7a of the Form 55002017-06-30204
Total of all active and inactive participants2017-06-30204
Total participants2017-06-30204
2016: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2016 401k membership
Total participants, beginning-of-year2016-06-01125
Total number of active participants reported on line 7a of the Form 55002016-06-01125
Total of all active and inactive participants2016-06-01125
Total participants2016-06-01125
2015: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2015 401k membership
Total participants, beginning-of-year2015-06-01140
Total number of active participants reported on line 7a of the Form 55002015-06-01140
Total of all active and inactive participants2015-06-01140
Total participants2015-06-01140
2014: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2014 401k membership
Total participants, beginning-of-year2014-07-0177
Total number of active participants reported on line 7a of the Form 55002014-07-0177
Total of all active and inactive participants2014-07-0177
Total participants2014-07-0177
2013: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2013 401k membership
Total participants, beginning-of-year2013-07-01105
Total number of active participants reported on line 7a of the Form 55002013-07-01105
Total of all active and inactive participants2013-07-01105
Total participants2013-07-01105
2012: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2012 401k membership
Total participants, beginning-of-year2012-07-01110
Total number of active participants reported on line 7a of the Form 55002012-07-01110
Total of all active and inactive participants2012-07-01110
Total participants2012-07-01110
2011: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2011 401k membership
Total participants, beginning-of-year2011-07-01105
Total number of active participants reported on line 7a of the Form 55002011-07-01105
Total of all active and inactive participants2011-07-01105
Total participants2011-07-01105
2010: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2010 401k membership
Total participants, beginning-of-year2010-06-01131
Total number of active participants reported on line 7a of the Form 55002010-06-01131
Total of all active and inactive participants2010-06-01131
Total participants2010-06-01131
2009: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2009 401k membership
Total participants, beginning-of-year2009-06-01126
Total number of active participants reported on line 7a of the Form 55002009-06-01126
Total of all active and inactive participants2009-06-01126
Total participants2009-06-01126

Form 5500 Responses for LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE

2022: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2019: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – InsuranceYes
2018: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – InsuranceYes
2017: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2017 form 5500 responses
2017-06-30Type of plan entitySingle employer plan
2017-06-30Submission has been amendedNo
2017-06-30This submission is the final filingNo
2017-06-30This return/report is a short plan year return/report (less than 12 months)No
2017-06-30Plan is a collectively bargained planNo
2017-06-30Plan funding arrangement – InsuranceYes
2017-06-30Plan benefit arrangement – InsuranceYes
2016: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – InsuranceYes
2015: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – InsuranceYes
2014: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2013 form 5500 responses
2013-07-01Type of plan entityMulitple employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2010: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2010 form 5500 responses
2010-06-01Type of plan entitySingle employer plan
2010-06-01Submission has been amendedNo
2010-06-01This submission is the final filingNo
2010-06-01This return/report is a short plan year return/report (less than 12 months)No
2010-06-01Plan is a collectively bargained planNo
2010-06-01Plan funding arrangement – InsuranceYes
2010-06-01Plan benefit arrangement – InsuranceYes
2009: LA PAZ REGIONAL HOSPITAL BENEFIT PLAN-LIFE 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01First time form 5500 has been submittedYes
2009-06-01Submission has been amendedYes
2009-06-01This submission is the final filingNo
2009-06-01This return/report is a short plan year return/report (less than 12 months)No
2009-06-01Plan is a collectively bargained planNo
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0430I
Policy instance 3
Insurance contract or identification numberGVTL0430I
Number of Individuals Covered81
Insurance policy start date2022-01-01
Insurance policy end date2023-01-01
Total amount of commissions paid to insurance brokerUSD $5,613
Total amount of fees paid to insurance companyUSD $2,251
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,613
Amount paid for insurance broker fees2251
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0430I
Policy instance 2
Insurance contract or identification numberGLUG0430I
Number of Individuals Covered166
Insurance policy start date2022-01-01
Insurance policy end date2023-01-01
Total amount of commissions paid to insurance brokerUSD $3,129
Total amount of fees paid to insurance companyUSD $1,535
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,129
Amount paid for insurance broker fees1535
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGTL0403I
Policy instance 1
Insurance contract or identification numberGTL0403I
Number of Individuals Covered166
Insurance policy start date2022-01-01
Insurance policy end date2023-01-01
Total amount of commissions paid to insurance brokerUSD $3,833
Total amount of fees paid to insurance companyUSD $2,349
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0403I
Policy instance 1
Insurance contract or identification numberGLTD0403I
Number of Individuals Covered174
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $3,999
Total amount of fees paid to insurance companyUSD $1,826
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $50,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,999
Amount paid for insurance broker fees1826
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0430I
Policy instance 2
Insurance contract or identification numberGLUG0430I
Number of Individuals Covered174
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $3,287
Total amount of fees paid to insurance companyUSD $1,293
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $36,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,287
Amount paid for insurance broker fees1293
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0430I
Policy instance 3
Insurance contract or identification numberGVTL0430I
Number of Individuals Covered88
Insurance policy start date2019-07-01
Insurance policy end date2020-07-01
Total amount of commissions paid to insurance brokerUSD $7,209
Total amount of fees paid to insurance companyUSD $1,700
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,209
Amount paid for insurance broker fees1700
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0430I
Policy instance 1
Insurance contract or identification numberGLTD0430I
Number of Individuals Covered176
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $3,990
Total amount of fees paid to insurance companyUSD $2,188
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,990
Amount paid for insurance broker fees2188
Additional information about fees paid to insurance brokerOTHER COMPENSATION TO AGENT OF RECORD
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0430I
Policy instance 3
Insurance contract or identification numberGVTL0430I
Number of Individuals Covered87
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $6,467
Total amount of fees paid to insurance companyUSD $1,776
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $43,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,467
Amount paid for insurance broker fees1776
Additional information about fees paid to insurance brokerOTHER COMPENSATION TO AGENT
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0430I
Policy instance 2
Insurance contract or identification numberGLUG0430I
Number of Individuals Covered176
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $3,316
Total amount of fees paid to insurance companyUSD $1,869
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $36,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,316
Amount paid for insurance broker fees1869
Additional information about fees paid to insurance brokerOTHER COMPENSATION FOR AGENT
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD430I
Policy instance 1
Insurance contract or identification numberGLTD430I
Number of Individuals Covered176
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $3,990
Total amount of fees paid to insurance companyUSD $2,188
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,990
Amount paid for insurance broker fees2188
Additional information about fees paid to insurance brokerOTHER COMPENSATION TO AGENT OF RECORD
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0430I
Policy instance 3
Insurance contract or identification numberGLUG0430I
Number of Individuals Covered204
Insurance policy start date2017-06-30
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $3,265
Total amount of fees paid to insurance companyUSD $1,268
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,265
Amount paid for insurance broker fees1268
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SVS INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000430I
Policy instance 2
Insurance contract or identification numberG000430I
Number of Individuals Covered204
Insurance policy start date2017-06-30
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $3,265
Total amount of fees paid to insurance companyUSD $1,268
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,265
Amount paid for insurance broker fees1268
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SVS INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0430I
Policy instance 1
Insurance contract or identification numberGVTL0430I
Number of Individuals Covered204
Insurance policy start date2017-06-30
Insurance policy end date2018-07-01
Total amount of commissions paid to insurance brokerUSD $3,279
Total amount of fees paid to insurance companyUSD $1,484
Are there contracts with allocated funds for individual policies?1
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,279
Amount paid for insurance broker fees1484
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SVS INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGTLD04301
Policy instance 1
Insurance contract or identification numberGTLD04301
Number of Individuals Covered137
Insurance policy start date2015-06-01
Insurance policy end date2016-06-01
Total amount of commissions paid to insurance brokerUSD $3,762
Total amount of fees paid to insurance companyUSD $1,629
Are there contracts with allocated funds for individual policies?Yes
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,762
Amount paid for insurance broker fees1629
Additional information about fees paid to insurance brokerAGNET OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SVS INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG0004301
Policy instance 1
Insurance contract or identification numberG0004301
Number of Individuals Covered77
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $5,284
Total amount of fees paid to insurance companyUSD $1,795
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,284
Amount paid for insurance broker fees1795
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD OTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SVS INC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5428265
Policy instance 1
Insurance contract or identification number5428265
Number of Individuals Covered105
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $5,158
Total amount of fees paid to insurance companyUSD $513
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $31,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,158
Amount paid for insurance broker fees513
Additional information about fees paid to insurance brokerFEES & OTHER COMMISSIONS
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INS SERV
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5428265
Policy instance 1
Insurance contract or identification number5428265
Number of Individuals Covered110
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $4,858
Total amount of fees paid to insurance companyUSD $482
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $48,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,858
Amount paid for insurance broker fees482
Additional information about fees paid to insurance brokerDENTAL INSURANCE
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERV
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5428265
Policy instance 1
Insurance contract or identification number5428265
Number of Individuals Covered105
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $4,963
Total amount of fees paid to insurance companyUSD $246
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000430I
Policy instance 2
Insurance contract or identification numberG000430I
Number of Individuals Covered131
Insurance policy start date2010-06-01
Insurance policy end date2011-06-01
Total amount of commissions paid to insurance brokerUSD $4,595
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,245
Commission paid to Insurance BrokerUSD $3,049
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROCKER OF RECORD
Insurance broker organization code?3
Insurance broker nameERIN P COLLINS AND ASSOCIATES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000430I
Policy instance 3
Insurance contract or identification numberG000430I
Number of Individuals Covered69
Insurance policy start date2010-06-01
Insurance policy end date2011-06-01
Total amount of commissions paid to insurance brokerUSD $5,713
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE AND AD & D
Welfare Benefit Premiums Paid to CarrierUSD $31,635
Commission paid to Insurance BrokerUSD $3,799
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROCKER OF RECORD
Insurance broker organization code?3
Insurance broker nameERIN P COLLINS AND ASSOCIATES INC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000430I
Policy instance 1
Insurance contract or identification numberG000430I
Number of Individuals Covered131
Insurance policy start date2010-06-01
Insurance policy end date2011-06-01
Total amount of commissions paid to insurance brokerUSD $3,507
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,818
Commission paid to Insurance BrokerUSD $2,434
Additional information about fees paid to insurance brokerAGENT OR BROCKER OF RECORD
Insurance broker organization code?3
Insurance broker nameERIN P COLLINS AND ASSOCIATES INC

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