MOSES LAKE INDUSTRIES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN
401k plan membership statisitcs for MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 419 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 416 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 416 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 392 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 428 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 430 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 355 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 372 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 372 |
| Total participants | 2020-01-01 | 372 |
| 2019: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 333 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 345 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 10 |
| Total of all active and inactive participants | 2019-01-01 | 357 |
| Total participants | 2019-01-01 | 357 |
| 2018: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 320 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 329 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 8 |
| Total of all active and inactive participants | 2018-01-01 | 338 |
| Total participants | 2018-01-01 | 338 |
| 2017: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 291 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 311 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 4 |
| Total of all active and inactive participants | 2017-01-01 | 316 |
| Total participants | 2017-01-01 | 316 |
| 2016: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 291 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 7 |
| Total of all active and inactive participants | 2016-01-01 | 299 |
| Total participants | 2016-01-01 | 299 |
| 2015: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 240 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 264 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 2 |
| Total of all active and inactive participants | 2015-01-01 | 267 |
| Total participants | 2015-01-01 | 267 |
| 2014: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 237 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 5 |
| Total of all active and inactive participants | 2014-01-01 | 245 |
| Total participants | 2014-01-01 | 245 |
| 2013: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 237 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-11-01 | 9 |
| Total of all active and inactive participants | 2013-11-01 | 246 |
| Total participants | 2013-11-01 | 246 |
| 2012: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 237 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 7 |
| Total of all active and inactive participants | 2012-11-01 | 244 |
| Total participants | 2012-11-01 | 244 |
| 2011: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 207 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 6 |
| Total of all active and inactive participants | 2011-11-01 | 213 |
| Total participants | 2011-11-01 | 213 |
| 2009: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 168 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 1 |
| Total of all active and inactive participants | 2009-11-01 | 169 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-11-01 | 0 |
| Total participants | 2009-11-01 | 169 |
| 2022: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Submission has been amended | No |
| 2013-11-01 | This submission is the final filing | No |
| 2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-11-01 | Plan is a collectively bargained plan | No |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | No |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: MOSES LAKE INDUSTRIES INC HEALTH & WELFARE PLAN 2008 form 5500 responses |
|---|
| 2008-11-01 | Type of plan entity | Single employer plan |
| 2008-11-01 | Submission has been amended | No |
| 2008-11-01 | This submission is the final filing | No |
| 2008-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-11-01 | Plan is a collectively bargained plan | No |
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | AGC0000980288 |
| Policy instance | 4 |
| Insurance contract or identification number | AGC0000980288 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,481 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $14,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,487 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 3 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,045 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,045 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 2 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $9,224 | | Total amount of fees paid to insurance company | USD $6,379 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $267,036 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,224 | | Amount paid for insurance broker fees | 6379 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 1008 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $27,040 | | 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 | | Commission paid to Insurance Broker | USD $27,040 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 613 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $26,027 | | 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 | | Commission paid to Insurance Broker | USD $25,970 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 2 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 438 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $9,674 | | Total amount of fees paid to insurance company | USD $3,380 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $270,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,674 | | Amount paid for insurance broker fees | 3380 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 3 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 418 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,077 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,840 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,077 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | F3T10 |
| Policy instance | 4 |
| Insurance contract or identification number | F3T10 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,844 | | Total amount of fees paid to insurance company | USD $909 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $69,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,991 | | Amount paid for insurance broker fees | 653 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 07353 |
| Policy instance | 1 |
| Insurance contract or identification number | 07353 | | Number of Individuals Covered | 941 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $23,814 | | Total amount of fees paid to insurance company | USD $70,301 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,813 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 2 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 373 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $8,516 | | 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 | 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 | | 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 $190,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,516 | | Amount paid for insurance broker fees | 3333 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 3 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,972 | | 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 | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $56,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,476 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 4 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $43,300 | | Total amount of fees paid to insurance company | USD $1,589 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,300 | | Amount paid for insurance broker fees | 1589 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 5 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 367 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $38,418 | | Total amount of fees paid to insurance company | USD $48,396 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,418 | | Amount paid for insurance broker fees | 48396 | | Additional information about fees paid to insurance broker | ENHANCED COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | F3T10 |
| Policy instance | 6 |
| Insurance contract or identification number | F3T10 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $18,053 | | Total amount of fees paid to insurance company | USD $635 | | 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 | | 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 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 07353 |
| Policy instance | 1 |
| Insurance contract or identification number | 07353 | | Number of Individuals Covered | 913 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $21,523 | | Total amount of fees paid to insurance company | USD $73,308 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $35,746 | | Total amount of fees paid to insurance company | USD $48,477 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,947 | | Additional information about fees paid to insurance broker | STOP LOSS | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 48477 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $41,370 | | Total amount of fees paid to insurance company | USD $2,113 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,370 | | Amount paid for insurance broker fees | 2113 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,883 | | Total amount of fees paid to insurance company | USD $3,426 | | 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 | 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 | | 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 $195,746 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $8,883 | | Amount paid for insurance broker fees | 3426 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 5 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 351 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,934 | | 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 | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,934 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | F3T10 |
| Policy instance | 6 |
| Insurance contract or identification number | F3T10 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,340 | | Total amount of fees paid to insurance company | USD $712 | | 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 | | 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 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 1 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $41,370 | | Total amount of fees paid to insurance company | USD $2,113 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,370 | | Amount paid for insurance broker fees | 2113 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 07353 |
| Policy instance | 2 |
| Insurance contract or identification number | 07353 | | Number of Individuals Covered | 913 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $21,523 | | Total amount of fees paid to insurance company | USD $73,308 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | F3T10 |
| Policy instance | 3 |
| Insurance contract or identification number | F3T10 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,340 | | Total amount of fees paid to insurance company | USD $712 | | 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 | | 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 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 4 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $32,799 | | Total amount of fees paid to insurance company | USD $48,477 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,799 | | Amount paid for insurance broker fees | 48477 | | Additional information about fees paid to insurance broker | STOP LOSS | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 6 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,883 | | Total amount of fees paid to insurance company | USD $3,426 | | 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 | 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 | | 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 $195,746 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $8,883 | | Amount paid for insurance broker fees | 3426 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 07353 |
| Policy instance | 1 |
| Insurance contract or identification number | 07353 | | Number of Individuals Covered | 331 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $20,781 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,781 | | Insurance broker organization code? | 3 |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of fees paid to insurance company | USD $49,795 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 49795 | | Additional information about fees paid to insurance broker | ENHANCED COMPENSATION | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $39,290 | | Total amount of fees paid to insurance company | USD $2,916 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,290 | | Amount paid for insurance broker fees | 2916 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 4 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 334 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,893 | | 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 | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,604 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,893 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 5 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,535 | | 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 | 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 | | 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 $171,145 | | 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 | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 8023352 |
| Policy instance | 6 |
| Insurance contract or identification number | 8023352 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $551 | | 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 | 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 | ISTDPROTEC, ISWL STND | | 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 $29,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $551 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 6 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $1,901 | | 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 | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,746 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1901 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC - ARGUS |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 8023352 |
| Policy instance | 5 |
| Insurance contract or identification number | 8023352 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $650 | | 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 | 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 | ISTDPROTEC, ISWL STND | | 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 $33,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $650 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 321 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,393 | | 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 | 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 | | 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 $158,821 | | 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 | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HUB INTERNATIONAL NW LLC |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 317 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $37,440 | | Total amount of fees paid to insurance company | USD $2,612 | | 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 $256,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,440 | | Amount paid for insurance broker fees | 2612 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $20,412 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 20412 | | Additional information about fees paid to insurance broker | ENHANCED COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW MOSES LAKE |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 07353 |
| Policy instance | 1 |
| Insurance contract or identification number | 07353 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $20,730 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,730 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC - ARGUS |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $13,694 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,694 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW - ARGUS |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $43,536 | | 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 | | 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 $435,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,536 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW MOSES LAKE |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $29,510 | | Total amount of fees paid to insurance company | USD $1,703 | | 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 $245,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,510 | | Amount paid for insurance broker fees | 1703 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NORTHWEST LLC |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008023352 |
| Policy instance | 4 |
| Insurance contract or identification number | 0008023352 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $642 | | 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 | ISTDPROTEC, ISWL STND | | 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 $32,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $642 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NORTHWEST LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30016467 |
| Policy instance | 5 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,411 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,411 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC - ARGUS |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 225 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW LLC-MOSES LAKE |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $14,792 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,792 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW - ARGUS |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,483 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ADD | | 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 $113,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,483 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30016467 |
| Policy instance | 5 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,354 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,016 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $37,889 | | 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 | | 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 $378,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,889 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NW MOSES LAKE |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,451 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,451 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NORTHWEST - ARGUS |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $5,280 | | 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 | | 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 $52,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,280 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC - MOSES LAKE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $1,302 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ADD | | 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 $18,571 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,302 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30016467 |
| Policy instance | 5 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $504 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $504 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,740 | | 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 $41,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,740 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC - MOSES LAKE |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30016467 |
| Policy instance | 5 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $1,385 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,385 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-11-01 | | Total amount of commissions paid to insurance broker | USD $7,600 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ADD | | 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 $104,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,600 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 3 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $32,786 | | 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 $568,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,786 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC - MOSES LAKE |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 1 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $14,110 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,110 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL NORTHWEST - ARGUS |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | 8537 |
| Policy instance | 2 |
| Insurance contract or identification number | 8537 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $26,065 | | 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 | | 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 $260,653 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,065 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ARGUS INSURANCE INC - MOSES LAKE |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 1 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $55,011 | | Total amount of fees paid to insurance company | USD $4,573 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,200,437 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 2 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $11,931 | | 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? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30016467 |
| Policy instance | 3 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $1,307 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,706 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008023352 |
| Policy instance | 4 |
| Insurance contract or identification number | 0008023352 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $1,435 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VWB (ACCIDENT, ISTDPROTEC, ISWL STND) | | Welfare Benefit Premiums Paid to Carrier | USD $47,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 146554 |
| Policy instance | 5 |
| Insurance contract or identification number | 146554 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-11-01 | | Total amount of commissions paid to insurance broker | USD $7,017 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $81,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30016467 |
| Policy instance | 1 |
| Insurance contract or identification number | 30016467 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $1,225 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,963 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1017637 |
| Policy instance | 2 |
| Insurance contract or identification number | 1017637 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $50,117 | | Total amount of fees paid to insurance company | USD $1,250 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,005,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 7353 |
| Policy instance | 3 |
| Insurance contract or identification number | 7353 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $11,823 | | 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? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000146554 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000146554 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $7,322 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $79,430 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008023352 |
| Policy instance | 5 |
| Insurance contract or identification number | 0008023352 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $2,101 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VWB (ACCIDENT, ISWL STND) | | Welfare Benefit Premiums Paid to Carrier | USD $48,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
