UNIVERSAL LASER SYSTEMS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN
401k plan membership statisitcs for UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-01 | 96 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 83 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 0 |
| Total of all active and inactive participants | 2022-12-01 | 83 |
| Number of employers contributing to the scheme | 2022-12-01 | 0 |
| 2021: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 96 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 96 |
| Number of employers contributing to the scheme | 2021-12-01 | 0 |
| 2019: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 87 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 101 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2018: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 167 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 167 |
| 2017: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 155 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 156 |
| 2016: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 160 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 163 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 165 |
| 2015: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 159 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 1 |
| Total of all active and inactive participants | 2015-12-01 | 160 |
| Total participants | 2015-12-01 | 160 |
| 2014: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 163 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 167 |
| 2013: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 149 |
| Number of retired or separated participants receiving benefits | 2013-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-01 | 0 |
| Total of all active and inactive participants | 2013-12-01 | 152 |
| 2012: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 120 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 121 |
| 2011: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 125 |
| Number of retired or separated participants receiving benefits | 2011-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-01 | 0 |
| Total of all active and inactive participants | 2011-12-01 | 125 |
| 2010: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 108 |
| Number of retired or separated participants receiving benefits | 2010-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-01 | 0 |
| Total of all active and inactive participants | 2010-12-01 | 108 |
| 2009: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 113 |
| Number of retired or separated participants receiving benefits | 2009-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-01 | 0 |
| Total of all active and inactive participants | 2009-12-01 | 113 |
| 2008: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-12-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-12-01 | 107 |
| Number of retired or separated participants receiving benefits | 2008-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-12-01 | 0 |
| Total of all active and inactive participants | 2008-12-01 | 107 |
| 2007: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-12-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-12-01 | 124 |
| Number of retired or separated participants receiving benefits | 2007-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-12-01 | 0 |
| Total of all active and inactive participants | 2007-12-01 | 124 |
| 2022: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | Yes |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Submission has been amended | No |
| 2017-12-01 | This submission is the final filing | No |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-12-01 | Plan is a collectively bargained plan | No |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2008 form 5500 responses |
|---|
| 2008-12-01 | Type of plan entity | Single employer plan |
| 2008-12-01 | Submission has been amended | No |
| 2008-12-01 | This submission is the final filing | No |
| 2008-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-12-01 | Plan is a collectively bargained plan | No |
| 2008-12-01 | Plan funding arrangement – Insurance | Yes |
| 2008-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: UNIVERSAL LASER SYSTEMS, INC. WELFARE BENEFIT PLAN 2007 form 5500 responses |
|---|
| 2007-12-01 | Type of plan entity | Single employer plan |
| 2007-12-01 | First time form 5500 has been submitted | Yes |
| 2007-12-01 | Submission has been amended | No |
| 2007-12-01 | This submission is the final filing | No |
| 2007-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-12-01 | Plan is a collectively bargained plan | No |
| 2007-12-01 | Plan funding arrangement – Insurance | Yes |
| 2007-12-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BZRN |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BZRN | | Number of Individuals Covered | 83 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $7,021 | | Total amount of fees paid to insurance company | USD $3,561 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $58,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,021 | | Amount paid for insurance broker fees | 3561 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16058 ) |
| Policy contract number | 175244BH |
| Policy instance | 4 |
| Insurance contract or identification number | 175244BH | | Number of Individuals Covered | 127 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $44,531 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $658,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 44531 | | Additional information about fees paid to insurance broker | 2022 Q4 BANNER HEALTH JOINT VENTURE INCENTIVE RISK, DIRECT COMPENSATION | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 175244 |
| Policy instance | 3 |
| Insurance contract or identification number | 175244 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,962 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 3962 | | Additional information about fees paid to insurance broker | 2022 Q4 SIGNATURE MEDICAL NEW BUSINESS INCENTIVE RISK, DIRECT COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30922-16 |
| Policy instance | 2 |
| Insurance contract or identification number | 30922-16 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $1,038 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $813 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 37062 |
| Policy instance | 1 |
| Insurance contract or identification number | 37062 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $3,916 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,916 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00634296 |
| Policy instance | 3 |
| Insurance contract or identification number | 00634296 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $42,223 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $745,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 31622 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEES |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 55755 37062 |
| Policy instance | 2 |
| Insurance contract or identification number | 55755 37062 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $3,997 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,319 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0906249 |
| Policy instance | 1 |
| Insurance contract or identification number | 0906249 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $779 | | Total amount of fees paid to insurance company | USD $-12 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $779 | | Amount paid for insurance broker fees | -12 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BZRN |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BZRN | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $7,069 | | Total amount of fees paid to insurance company | USD $180 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $58,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,069 | | Amount paid for insurance broker fees | 180 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 035165 |
| Policy instance | 2 |
| Insurance contract or identification number | 035165 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $61,785 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $987,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,785 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 006398 |
| Policy instance | 3 |
| Insurance contract or identification number | 006398 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $6,800 | | Total amount of fees paid to insurance company | USD $2,833 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $56,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,800 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2833 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 55755 37062 |
| Policy instance | 4 |
| Insurance contract or identification number | 55755 37062 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $5,074 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,074 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0906249 |
| Policy instance | 1 |
| Insurance contract or identification number | 0906249 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,230 | | Total amount of fees paid to insurance company | USD $617 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 617 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 ) |
| Policy contract number | 55755 37062 |
| Policy instance | 4 |
| Insurance contract or identification number | 55755 37062 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $6,477 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,477 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 304856 |
| Policy instance | 3 |
| Insurance contract or identification number | 304856 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $4,881 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $76,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,881 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 035165 |
| Policy instance | 2 |
| Insurance contract or identification number | 035165 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $77,419 | | 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 $1,303,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77,357 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906249 |
| Policy instance | 1 |
| Insurance contract or identification number | 906249 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,501 | | Total amount of fees paid to insurance company | USD $144 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,218 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,501 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 144 | | Additional information about fees paid to insurance broker | BONUS AMOUNT |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-046404 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-046404 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $7,096 | | Total amount of fees paid to insurance company | USD $720 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LASIK, HEARING | | Welfare Benefit Premiums Paid to Carrier | USD $70,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0906249 |
| Policy instance | 1 |
| Insurance contract or identification number | 0906249 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,472 | | Total amount of fees paid to insurance company | USD $6,077 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $111,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 53589 |
| Policy instance | 2 |
| Insurance contract or identification number | 53589 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $30,161 | | 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 $1,222,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 304856 |
| Policy instance | 3 |
| Insurance contract or identification number | 304856 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $4,098 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $60,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 5 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $2,266 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,266 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 540174 |
| Policy instance | 2 |
| Insurance contract or identification number | 540174 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $1,399 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,994 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,399 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 1 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $2,521 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,521 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 4 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,624 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,624 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0804542 |
| Policy instance | 3 |
| Insurance contract or identification number | 0804542 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $73,401 | | Total amount of fees paid to insurance company | USD $43 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,188,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73,401 | | Amount paid for insurance broker fees | 43 | | Additional information about fees paid to insurance broker | PM CROSS-SALE | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0804542 |
| Policy instance | 3 |
| Insurance contract or identification number | 0804542 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $54,066 | | Total amount of fees paid to insurance company | USD $21,181 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $944,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,066 | | Amount paid for insurance broker fees | 21181 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 4 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,542 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,542 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 5 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,877 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,638 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,877 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 1 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,536 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,536 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 540174 |
| Policy instance | 2 |
| Insurance contract or identification number | 540174 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $1,326 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,326 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 540174 |
| Policy instance | 2 |
| Insurance contract or identification number | 540174 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $1,117 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,117 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 1 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $2,354 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,354 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 897232-000,-099 |
| Policy instance | 3 |
| Insurance contract or identification number | 897232-000,-099 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $4,869 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,869 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 717985 |
| Policy instance | 4 |
| Insurance contract or identification number | 717985 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $46,620 | | Total amount of fees paid to insurance company | USD $1,080 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $776,994 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,620 | | Amount paid for insurance broker fees | 1080 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 5 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $1,336 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,136 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,336 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 6 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $1,597 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,597 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 4 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,477 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,477 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 7 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,265 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,265 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR ASSOCIATES INC. |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 897232-000,-099 |
| Policy instance | 6 |
| Insurance contract or identification number | 897232-000,-099 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $4,643 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,643 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR ASSOCIATES INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05775793 |
| Policy instance | 5 |
| Insurance contract or identification number | KM05775793 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $379 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $379 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0717985 |
| Policy instance | 3 |
| Insurance contract or identification number | 0717985 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $45,822 | | Total amount of fees paid to insurance company | USD $1,710 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $763,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,822 | | Amount paid for insurance broker fees | 1710 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 540174 |
| Policy instance | 2 |
| Insurance contract or identification number | 540174 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $1,048 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,048 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 1 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $2,114 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,114 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05775793 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05775793 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $4,070 | | Total amount of fees paid to insurance company | USD $73 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,070 | | Amount paid for insurance broker fees | 73 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 1 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $1,119 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,119 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 22260 |
| Policy instance | 3 |
| Insurance contract or identification number | 22260 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $993 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,926 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $993 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR PEDERSON |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 4 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $1,388 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,388 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0717985 |
| Policy instance | 5 |
| Insurance contract or identification number | 0717985 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $39,216 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $653,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,061 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 6 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $1,833 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,833 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 857659-000,-099 |
| Policy instance | 4 |
| Insurance contract or identification number | 857659-000,-099 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $5,425 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,425 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0717985 |
| Policy instance | 2 |
| Insurance contract or identification number | 0717985 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $38,260 | | Total amount of fees paid to insurance company | USD $2,220 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $637,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,260 | | Amount paid for insurance broker fees | 2220 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 3 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $1,944 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,944 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 5 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $1,373 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,373 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 22260 |
| Policy instance | 1 |
| Insurance contract or identification number | 22260 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $991 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $991 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR PEDERSON |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 6 |
| Insurance contract or identification number | 010732 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Total amount of commissions paid to insurance broker | USD $1,026 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,026 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 010732 |
| Policy instance | 2 |
| Insurance contract or identification number | 010732 | | Insurance policy start date | 2008-06-01 | | Insurance policy end date | 2009-05-31 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 857659-000,-099 |
| Policy instance | 1 |
| Insurance contract or identification number | 857659-000,-099 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2008-12-01 | | Insurance policy end date | 2009-11-30 | | Total amount of commissions paid to insurance broker | USD $4,046 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,558 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,046 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 22260 |
| Policy instance | 3 |
| Insurance contract or identification number | 22260 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2008-12-01 | | Insurance policy end date | 2009-11-30 | | Total amount of commissions paid to insurance broker | USD $971 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,708 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $971 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR PEDERSON |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | 707076 |
| Policy instance | 4 |
| Insurance contract or identification number | 707076 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2008-12-01 | | Insurance policy end date | 2009-11-30 | | Total amount of commissions paid to insurance broker | USD $28,375 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $603,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,375 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS, INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 425804 |
| Policy instance | 1 |
| Insurance contract or identification number | 425804 | | Insurance policy start date | 2008-06-01 | | Insurance policy end date | 2008-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | 707076 |
| Policy instance | 2 |
| Insurance contract or identification number | 707076 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2007-12-01 | | Insurance policy end date | 2008-11-30 | | Total amount of commissions paid to insurance broker | USD $34,258 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $580,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,258 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| SIGHTCARE, INC (National Association of Insurance Commissioners NAIC id number: 47012 ) |
| Policy contract number | 22260 |
| Policy instance | 3 |
| Insurance contract or identification number | 22260 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2007-12-01 | | Insurance policy end date | 2008-11-30 | | Total amount of commissions paid to insurance broker | USD $1,143 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,143 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR PEDERSON |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 54232 |
| Policy instance | 5 |
| Insurance contract or identification number | 54232 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2007-06-01 | | Insurance policy end date | 2008-05-31 | | Total amount of commissions paid to insurance broker | USD $4,639 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,655 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,639 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 425804 |
| Policy instance | 4 |
| Insurance contract or identification number | 425804 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2007-06-01 | | Insurance policy end date | 2008-05-31 | | Total amount of commissions paid to insurance broker | USD $4,768 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,926 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $175 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR INSURANCE AGENCY |
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