FOG ENTERPRISE, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN
Measure | Date | Value |
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2019: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-09-01 | 100 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 75 |
Number of retired or separated participants receiving benefits | 2019-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
Total of all active and inactive participants | 2019-09-01 | 75 |
2018: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-09-01 | 102 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 143 |
Number of retired or separated participants receiving benefits | 2018-09-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
Total of all active and inactive participants | 2018-09-01 | 144 |
2017: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-09-01 | 156 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 143 |
Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 13 |
Total of all active and inactive participants | 2017-09-01 | 156 |
2016: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-09-01 | 172 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 154 |
Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
Total of all active and inactive participants | 2016-09-01 | 154 |
2015: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-09-01 | 189 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 134 |
Number of retired or separated participants receiving benefits | 2015-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
Total of all active and inactive participants | 2015-09-01 | 134 |
2014: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-09-01 | 174 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 140 |
Number of retired or separated participants receiving benefits | 2014-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
Total of all active and inactive participants | 2014-09-01 | 140 |
2013: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-09-01 | 159 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 174 |
Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 0 |
Total of all active and inactive participants | 2013-09-01 | 174 |
2012: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-09-01 | 149 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 159 |
Number of retired or separated participants receiving benefits | 2012-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 0 |
Total of all active and inactive participants | 2012-09-01 | 159 |
2011: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-09-01 | 148 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 138 |
Number of retired or separated participants receiving benefits | 2011-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
Total of all active and inactive participants | 2011-09-01 | 138 |
2009: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-09-01 | 168 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 301 |
Number of retired or separated participants receiving benefits | 2009-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
Total of all active and inactive participants | 2009-09-01 | 301 |
2008: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2008 401k membership |
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Total participants, beginning-of-year | 2008-09-01 | 170 |
Total number of active participants reported on line 7a of the Form 5500 | 2008-09-01 | 168 |
Number of retired or separated participants receiving benefits | 2008-09-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2008-09-01 | 0 |
Total of all active and inactive participants | 2008-09-01 | 169 |
2007: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2007 401k membership |
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Total participants, beginning-of-year | 2007-09-01 | 228 |
Total number of active participants reported on line 7a of the Form 5500 | 2007-09-01 | 173 |
Number of retired or separated participants receiving benefits | 2007-09-01 | 2 |
Total of all active and inactive participants | 2007-09-01 | 175 |
2006: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2006 401k membership |
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Total participants, beginning-of-year | 2006-09-01 | 162 |
Total number of active participants reported on line 7a of the Form 5500 | 2006-09-01 | 232 |
Number of retired or separated participants receiving benefits | 2006-09-01 | 2 |
Total of all active and inactive participants | 2006-09-01 | 234 |
2019: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
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2019-09-01 | Type of plan entity | Single employer plan |
2019-09-01 | Submission has been amended | No |
2019-09-01 | This submission is the final filing | No |
2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-09-01 | Plan is a collectively bargained plan | No |
2019-09-01 | Plan funding arrangement – Insurance | Yes |
2019-09-01 | Plan benefit arrangement – Insurance | Yes |
2018: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
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2018-09-01 | Type of plan entity | Single employer plan |
2018-09-01 | Submission has been amended | No |
2018-09-01 | This submission is the final filing | No |
2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-09-01 | Plan is a collectively bargained plan | No |
2018-09-01 | Plan funding arrangement – Insurance | Yes |
2018-09-01 | Plan benefit arrangement – Insurance | Yes |
2017: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
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2017-09-01 | Type of plan entity | Single employer plan |
2017-09-01 | Submission has been amended | No |
2017-09-01 | This submission is the final filing | No |
2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-09-01 | Plan is a collectively bargained plan | No |
2017-09-01 | Plan funding arrangement – Insurance | Yes |
2017-09-01 | Plan benefit arrangement – Insurance | Yes |
2016: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
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2016-09-01 | Type of plan entity | Single employer plan |
2016-09-01 | Submission has been amended | No |
2016-09-01 | This submission is the final filing | No |
2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-09-01 | Plan is a collectively bargained plan | No |
2016-09-01 | Plan funding arrangement – Insurance | Yes |
2016-09-01 | Plan benefit arrangement – Insurance | Yes |
2015: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
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2015-09-01 | Type of plan entity | Single employer plan |
2015-09-01 | Submission has been amended | No |
2015-09-01 | This submission is the final filing | No |
2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-09-01 | Plan is a collectively bargained plan | No |
2015-09-01 | Plan funding arrangement – Insurance | Yes |
2015-09-01 | Plan benefit arrangement – Insurance | Yes |
2014: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
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2014-09-01 | Type of plan entity | Single employer plan |
2014-09-01 | Submission has been amended | No |
2014-09-01 | This submission is the final filing | No |
2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-09-01 | Plan is a collectively bargained plan | No |
2014-09-01 | Plan funding arrangement – Insurance | Yes |
2014-09-01 | Plan benefit arrangement – Insurance | Yes |
2013: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
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2013-09-01 | Type of plan entity | Single employer plan |
2013-09-01 | Submission has been amended | No |
2013-09-01 | This submission is the final filing | No |
2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-09-01 | Plan is a collectively bargained plan | No |
2013-09-01 | Plan funding arrangement – Insurance | Yes |
2013-09-01 | Plan benefit arrangement – Insurance | Yes |
2012: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
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2012-09-01 | Type of plan entity | Single employer plan |
2012-09-01 | Submission has been amended | No |
2012-09-01 | This submission is the final filing | No |
2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-09-01 | Plan is a collectively bargained plan | No |
2012-09-01 | Plan funding arrangement – Insurance | Yes |
2012-09-01 | Plan benefit arrangement – Insurance | Yes |
2011: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
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2011-09-01 | Type of plan entity | Single employer plan |
2011-09-01 | Submission has been amended | No |
2011-09-01 | This submission is the final filing | No |
2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-09-01 | Plan is a collectively bargained plan | No |
2011-09-01 | Plan funding arrangement – Insurance | Yes |
2011-09-01 | Plan benefit arrangement – Insurance | Yes |
2009: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
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2009-09-01 | Type of plan entity | Single employer plan |
2009-09-01 | Submission has been amended | No |
2009-09-01 | This submission is the final filing | No |
2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-09-01 | Plan is a collectively bargained plan | No |
2009-09-01 | Plan funding arrangement – Insurance | Yes |
2009-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-09-01 | Plan benefit arrangement – Insurance | Yes |
2009-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2008: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2008 form 5500 responses |
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2008-09-01 | Type of plan entity | Single employer plan |
2008-09-01 | Submission has been amended | Yes |
2008-09-01 | This submission is the final filing | No |
2008-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2008-09-01 | Plan is a collectively bargained plan | No |
2008-09-01 | Plan funding arrangement – Insurance | Yes |
2008-09-01 | Plan benefit arrangement – Insurance | Yes |
2007: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2007 form 5500 responses |
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2007-09-01 | Type of plan entity | Single employer plan |
2007-09-01 | Submission has been amended | No |
2007-09-01 | This submission is the final filing | No |
2007-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2007-09-01 | Plan is a collectively bargained plan | No |
2007-09-01 | Plan funding arrangement – Insurance | Yes |
2007-09-01 | Plan benefit arrangement – Insurance | Yes |
2006: FOG ENTERPRISE, LLC EMPLOYEE BENEFIT PLAN 2006 form 5500 responses |
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2006-09-01 | Type of plan entity | Single employer plan |
2006-09-01 | First time form 5500 has been submitted | Yes |
2006-09-01 | Submission has been amended | No |
2006-09-01 | This submission is the final filing | No |
2006-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2006-09-01 | Plan is a collectively bargained plan | No |
2006-09-01 | Plan funding arrangement – Insurance | Yes |
2006-09-01 | Plan benefit arrangement – Insurance | Yes |
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 131018 |
Policy instance | 2 |
Insurance contract or identification number | 131018 | Number of Individuals Covered | 57 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $18,893 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $432,802 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,893 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 1 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 88 | Insurance policy start date | 2019-09-01 | Insurance policy end date | 2020-08-31 | Total amount of commissions paid to insurance broker | USD $10,206 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $85,522 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,193 | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 131018 |
Policy instance | 2 |
Insurance contract or identification number | 131018 | Number of Individuals Covered | 94 | Insurance policy start date | 2018-09-01 | Insurance policy end date | 2019-08-31 | Total amount of commissions paid to insurance broker | USD $26,692 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $500,895 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,692 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 1 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 143 | Insurance policy start date | 2018-09-01 | Insurance policy end date | 2019-08-31 | Total amount of commissions paid to insurance broker | USD $12,272 | Total amount of fees paid to insurance company | USD $11,352 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $102,407 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,323 | Amount paid for insurance broker fees | 11352 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 131018 |
Policy instance | 2 |
Insurance contract or identification number | 131018 | Number of Individuals Covered | 135 | Insurance policy start date | 2017-09-01 | Insurance policy end date | 2018-08-31 | Total amount of commissions paid to insurance broker | USD $33,482 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $589,562 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $30,872 | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 1 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 130 | Insurance policy start date | 2017-09-01 | Insurance policy end date | 2018-08-31 | Total amount of commissions paid to insurance broker | USD $12,690 | Total amount of fees paid to insurance company | USD $12,870 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $105,365 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,690 | Amount paid for insurance broker fees | 12870 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY & ASSOCIATES, LLC |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 131018 |
Policy instance | 2 |
Insurance contract or identification number | 131018 | Number of Individuals Covered | 162 | Insurance policy start date | 2015-09-01 | Insurance policy end date | 2016-08-31 | Total amount of commissions paid to insurance broker | USD $40,348 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $787,985 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $40,348 | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 1 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 132 | Insurance policy start date | 2015-09-01 | Insurance policy end date | 2016-08-31 | Total amount of commissions paid to insurance broker | USD $13,159 | Total amount of fees paid to insurance company | USD $6,124 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $110,658 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,159 | Amount paid for insurance broker fees | 6124 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY & ASSOCIATES |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 664076 |
Policy instance | 1 |
Insurance contract or identification number | 664076 | Number of Individuals Covered | 167 | Insurance policy start date | 2014-09-01 | Insurance policy end date | 2015-08-31 | Total amount of commissions paid to insurance broker | USD $46,764 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $935,816 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,764 | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY & ASSOCIATES, LLC |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 2 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 120 | Insurance policy start date | 2014-09-01 | Insurance policy end date | 2015-08-31 | Total amount of commissions paid to insurance broker | USD $13,418 | Total amount of fees paid to insurance company | USD $7,489 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $115,602 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,418 | Amount paid for insurance broker fees | 7489 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY & ASSOCIATES |
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TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 ) |
Policy contract number | 00000 |
Policy instance | 3 |
Insurance contract or identification number | 00000 | Number of Individuals Covered | 140 | Insurance policy start date | 2014-09-01 | Insurance policy end date | 2015-08-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | TELEPHONE HEALTH CONSULTATION | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $650 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 ) |
Policy contract number | 00000 |
Policy instance | 3 |
Insurance contract or identification number | 00000 | Number of Individuals Covered | 139 | Insurance policy start date | 2013-09-01 | Insurance policy end date | 2014-08-31 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | TELEPHONE HEALTH CONSULTATION | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,600 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 118372 |
Policy instance | 1 |
Insurance contract or identification number | 118372 | Number of Individuals Covered | 233 | Insurance policy start date | 2013-09-01 | Insurance policy end date | 2014-08-31 | Total amount of commissions paid to insurance broker | USD $46,561 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,852 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,561 | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 2 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 174 | Insurance policy start date | 2013-09-01 | Insurance policy end date | 2014-08-31 | Total amount of commissions paid to insurance broker | USD $14,364 | Total amount of fees paid to insurance company | USD $4,931 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE, SUPPLEMENTAL AD&D, DEPENDENT AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $129,170 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,364 | Amount paid for insurance broker fees | 4931 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | WILLIAM R BLAKELY |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39188 |
Policy instance | 2 |
Insurance contract or identification number | H39188 | Number of Individuals Covered | 245 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $-20 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $-320 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $-20 | Insurance broker organization code? | 3 | Insurance broker name | WILLIAM RUSSELL BLAKELY |
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USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
Policy contract number | 50000758 |
Policy instance | 3 |
Insurance contract or identification number | 50000758 | Number of Individuals Covered | 127 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $131 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $466 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $70 | Insurance broker organization code? | 3 | Insurance broker name | GROUP INSURANCE SERVICES INC |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00480280 |
Policy instance | 4 |
Insurance contract or identification number | 00480280 | Number of Individuals Covered | 159 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2013-08-31 | Total amount of commissions paid to insurance broker | USD $12,550 | Total amount of fees paid to insurance company | USD $2,236 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOL. AD&D, VOL. LIFE | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $110,627 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,510 | Amount paid for insurance broker fees | 2236 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 | Insurance broker name | THE MATHIS-HILL-ROBERTSON AGENCY |
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USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
Policy contract number | 50000758 |
Policy instance | 5 |
Insurance contract or identification number | 50000758 | Number of Individuals Covered | 154 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $663 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOLUNTARY LIFE | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,368 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $355 | Insurance broker organization code? | 3 | Insurance broker name | GROUP INSURANCE SERVICES INC |
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USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
Policy contract number | 50000758 |
Policy instance | 6 |
Insurance contract or identification number | 50000758 | Number of Individuals Covered | 71 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $532 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOL. INCOME PROTECTION | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,898 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $285 | Insurance broker organization code? | 3 | Insurance broker name | GROUP INSURANCE SERVICES INC |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 118372 |
Policy instance | 1 |
Insurance contract or identification number | 118372 | Number of Individuals Covered | 246 | Insurance policy start date | 2012-09-01 | Insurance policy end date | 2013-08-31 | Total amount of commissions paid to insurance broker | USD $37,103 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,718 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,103 | Insurance broker organization code? | 3 | Insurance broker name | RUSS BLAKELY |
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USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
Policy contract number | 50000758 |
Policy instance | 3 |
Insurance contract or identification number | 50000758 | Number of Individuals Covered | 154 | Insurance policy start date | 2011-09-01 | Insurance policy end date | 2012-08-31 | Total amount of commissions paid to insurance broker | USD $16,310 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, ACCIDENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $60,061 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39188 |
Policy instance | 2 |
Insurance contract or identification number | H39188 | Number of Individuals Covered | 256 | Insurance policy start date | 2011-09-01 | Insurance policy end date | 2012-08-31 | Total amount of commissions paid to insurance broker | USD $4,525 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $74,700 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 118372 |
Policy instance | 1 |
Insurance contract or identification number | 118372 | Number of Individuals Covered | 254 | Insurance policy start date | 2011-09-01 | Insurance policy end date | 2012-08-31 | Total amount of commissions paid to insurance broker | USD $22,265 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $6,292 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
Policy contract number | 50000758 |
Policy instance | 3 |
Insurance contract or identification number | 50000758 | Number of Individuals Covered | 126 | Insurance policy start date | 2010-09-01 | Insurance policy end date | 2011-08-31 | Total amount of commissions paid to insurance broker | USD $13,597 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $51,177 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39188 |
Policy instance | 2 |
Insurance contract or identification number | H39188 | Number of Individuals Covered | 125 | Insurance policy start date | 2010-09-01 | Insurance policy end date | 2011-08-31 | Total amount of commissions paid to insurance broker | USD $4,278 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $70,190 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
Policy contract number | 118372 |
Policy instance | 1 |
Insurance contract or identification number | 118372 | Number of Individuals Covered | 275 | Insurance policy start date | 2010-09-01 | Insurance policy end date | 2011-08-31 | Total amount of commissions paid to insurance broker | USD $30,471 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $7,074 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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