TRI-CITY ORTHOPAEDIC CLINIC, PSC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN
401k plan membership statisitcs for TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN
Measure | Date | Value |
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2022: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-08-01 | 105 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-08-01 | 112 |
Number of retired or separated participants receiving benefits | 2022-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-08-01 | 0 |
Total of all active and inactive participants | 2022-08-01 | 112 |
2021: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-08-01 | 150 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-08-01 | 105 |
Number of retired or separated participants receiving benefits | 2021-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-08-01 | 0 |
Total of all active and inactive participants | 2021-08-01 | 105 |
2020: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-08-01 | 142 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 148 |
Number of retired or separated participants receiving benefits | 2020-08-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2020-08-01 | 0 |
Total of all active and inactive participants | 2020-08-01 | 150 |
2019: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-08-01 | 153 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 141 |
Number of retired or separated participants receiving benefits | 2019-08-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
Total of all active and inactive participants | 2019-08-01 | 142 |
2018: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-08-01 | 152 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 150 |
Number of retired or separated participants receiving benefits | 2018-08-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2018-08-01 | 0 |
Total of all active and inactive participants | 2018-08-01 | 153 |
2017: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-08-01 | 143 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 150 |
Number of retired or separated participants receiving benefits | 2017-08-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2017-08-01 | 0 |
Total of all active and inactive participants | 2017-08-01 | 152 |
2016: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-08-01 | 132 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 143 |
Number of retired or separated participants receiving benefits | 2016-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 0 |
Total of all active and inactive participants | 2016-08-01 | 143 |
2015: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-08-01 | 125 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 132 |
Number of retired or separated participants receiving benefits | 2015-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
Total of all active and inactive participants | 2015-08-01 | 132 |
2022: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2022 form 5500 responses |
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2022-08-01 | Type of plan entity | Single employer plan |
2022-08-01 | Submission has been amended | No |
2022-08-01 | This submission is the final filing | No |
2022-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-08-01 | Plan is a collectively bargained plan | No |
2022-08-01 | Plan funding arrangement – Insurance | Yes |
2022-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-08-01 | Plan benefit arrangement – Insurance | Yes |
2022-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2021 form 5500 responses |
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2021-08-01 | Type of plan entity | Single employer plan |
2021-08-01 | Submission has been amended | No |
2021-08-01 | This submission is the final filing | No |
2021-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-08-01 | Plan is a collectively bargained plan | No |
2021-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-08-01 | Plan benefit arrangement – Insurance | Yes |
2021-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2020 form 5500 responses |
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2020-08-01 | Type of plan entity | Single employer plan |
2020-08-01 | Submission has been amended | No |
2020-08-01 | This submission is the final filing | No |
2020-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-08-01 | Plan is a collectively bargained plan | No |
2020-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-08-01 | Plan benefit arrangement – Insurance | Yes |
2020-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2019 form 5500 responses |
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2019-08-01 | Type of plan entity | Single employer plan |
2019-08-01 | Submission has been amended | No |
2019-08-01 | This submission is the final filing | No |
2019-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-08-01 | Plan is a collectively bargained plan | No |
2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-08-01 | Plan benefit arrangement – Insurance | Yes |
2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2018 form 5500 responses |
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2018-08-01 | Type of plan entity | Single employer plan |
2018-08-01 | Submission has been amended | No |
2018-08-01 | This submission is the final filing | No |
2018-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-08-01 | Plan is a collectively bargained plan | No |
2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-08-01 | Plan benefit arrangement – Insurance | Yes |
2017: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2017 form 5500 responses |
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2017-08-01 | Type of plan entity | Single employer plan |
2017-08-01 | Submission has been amended | No |
2017-08-01 | This submission is the final filing | No |
2017-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-08-01 | Plan is a collectively bargained plan | No |
2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-08-01 | Plan benefit arrangement – Insurance | Yes |
2016: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2016 form 5500 responses |
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2016-08-01 | Type of plan entity | Single employer plan |
2016-08-01 | Submission has been amended | No |
2016-08-01 | This submission is the final filing | No |
2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-08-01 | Plan is a collectively bargained plan | No |
2016-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-08-01 | Plan benefit arrangement – Insurance | Yes |
2015: TRI-CITY ORTHOPAEDIC CLINIC, PSC WELFARE BENEFITS PLAN 2015 form 5500 responses |
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2015-08-01 | Type of plan entity | Single employer plan |
2015-08-01 | First time form 5500 has been submitted | Yes |
2015-08-01 | Submission has been amended | No |
2015-08-01 | This submission is the final filing | No |
2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-08-01 | Plan is a collectively bargained plan | No |
2015-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-08-01 | Plan benefit arrangement – Insurance | Yes |
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 5 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 78 | Insurance policy start date | 2022-08-01 | Insurance policy end date | 2023-07-31 | Total amount of commissions paid to insurance broker | USD $1,224 | 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 | 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 $14,743 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $975 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 4 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 33 | Insurance policy start date | 2022-08-01 | Insurance policy end date | 2023-07-31 | Total amount of commissions paid to insurance broker | USD $1,702 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $11,352 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,264 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 106 | Insurance policy start date | 2022-08-01 | Insurance policy end date | 2023-07-31 | Total amount of commissions paid to insurance broker | USD $225 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,249 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $170 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 2 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 59 | Insurance policy start date | 2022-08-01 | Insurance policy end date | 2023-07-31 | Total amount of commissions paid to insurance broker | USD $391 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,605 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $293 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 106 | Insurance policy start date | 2022-08-01 | Insurance policy end date | 2023-07-31 | Total amount of commissions paid to insurance broker | USD $2,621 | 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 | No | 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 $26,214 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,967 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 105 | Insurance policy start date | 2021-08-01 | Insurance policy end date | 2022-07-31 | Total amount of commissions paid to insurance broker | USD $279 | Total amount of fees paid to insurance company | USD $86 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,793 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $279 | Amount paid for insurance broker fees | 86 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 2 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 72 | Insurance policy start date | 2021-08-01 | Insurance policy end date | 2022-07-31 | Total amount of commissions paid to insurance broker | USD $1,055 | 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 | 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 $17,894 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,055 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 33 | Insurance policy start date | 2021-08-01 | Insurance policy end date | 2022-07-31 | Total amount of commissions paid to insurance broker | USD $305 | Total amount of fees paid to insurance company | USD $38 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,031 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $305 | Amount paid for insurance broker fees | 38 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 4 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 24 | Insurance policy start date | 2021-08-01 | Insurance policy end date | 2022-07-31 | Total amount of commissions paid to insurance broker | USD $1,820 | Total amount of fees paid to insurance company | USD $367 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $12,134 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,820 | Amount paid for insurance broker fees | 367 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 5 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 105 | Insurance policy start date | 2021-08-01 | Insurance policy end date | 2022-07-31 | Total amount of commissions paid to insurance broker | USD $3,053 | Total amount of fees paid to insurance company | USD $940 | 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 | 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 $31,062 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,053 | Amount paid for insurance broker fees | 940 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 5 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 102 | Insurance policy start date | 2020-08-01 | Insurance policy end date | 2021-07-31 | Total amount of commissions paid to insurance broker | USD $937 | 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 | 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 $19,760 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $937 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 4 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 31 | Insurance policy start date | 2020-08-01 | Insurance policy end date | 2021-07-31 | Total amount of commissions paid to insurance broker | USD $157 | Total amount of fees paid to insurance company | USD $26 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,045 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $157 | Amount paid for insurance broker fees | 26 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 35 | Insurance policy start date | 2020-08-01 | Insurance policy end date | 2021-07-31 | Total amount of commissions paid to insurance broker | USD $1,850 | Total amount of fees paid to insurance company | USD $390 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $12,335 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,850 | Amount paid for insurance broker fees | 390 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 2 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 148 | Insurance policy start date | 2020-08-01 | Insurance policy end date | 2021-07-31 | Total amount of commissions paid to insurance broker | USD $314 | Total amount of fees paid to insurance company | USD $92 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,140 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $314 | Amount paid for insurance broker fees | 92 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 148 | Insurance policy start date | 2020-08-01 | Insurance policy end date | 2021-07-31 | Total amount of commissions paid to insurance broker | USD $3,168 | Total amount of fees paid to insurance company | USD $938 | 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 | 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 $33,358 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,168 | Amount paid for insurance broker fees | 938 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 5 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 44 | Insurance policy start date | 2019-08-01 | Insurance policy end date | 2020-07-31 | Total amount of commissions paid to insurance broker | USD $2,142 | Total amount of fees paid to insurance company | USD $900 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,277 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 900 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 | Commission paid to Insurance Broker | USD $2,142 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 4 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 101 | Insurance policy start date | 2019-08-01 | Insurance policy end date | 2020-07-31 | Total amount of commissions paid to insurance broker | USD $1,114 | 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 | 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 $20,103 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,114 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 141 | Insurance policy start date | 2019-08-01 | Insurance policy end date | 2020-07-31 | Total amount of commissions paid to insurance broker | USD $320 | Total amount of fees paid to insurance company | USD $900 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,201 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 900 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 | Commission paid to Insurance Broker | USD $320 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 2 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 141 | Insurance policy start date | 2019-08-01 | Insurance policy end date | 2020-07-31 | Total amount of commissions paid to insurance broker | USD $3,091 | Total amount of fees paid to insurance company | USD $900 | 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 | 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 $31,815 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,091 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 900 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 31 | Insurance policy start date | 2019-08-01 | Insurance policy end date | 2020-07-31 | Total amount of commissions paid to insurance broker | USD $1,407 | 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 | 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 $9,377 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,407 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 53 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $2,085 | Total amount of fees paid to insurance company | USD $1,556 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,900 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,085 | Amount paid for insurance broker fees | 656 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 2 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 150 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $301 | Total amount of fees paid to insurance company | USD $1,032 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,011 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 900 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 | Commission paid to Insurance Broker | USD $301 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 45 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $3,048 | Total amount of fees paid to insurance company | USD $889 | 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 | 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 $20,318 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,048 | Amount paid for insurance broker fees | 889 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 4 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 103 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $1,056 | 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 | 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 $18,789 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,056 | Insurance broker organization code? | 3 |
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PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
Policy contract number | 4015692 |
Policy instance | 5 |
Insurance contract or identification number | 4015692 | Number of Individuals Covered | 117 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $6,772 | 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 | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,238,184 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 6772 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 6 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 150 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2019-07-31 | Total amount of commissions paid to insurance broker | USD $3,033 | Total amount of fees paid to insurance company | USD $2,208 | 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 | 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 $30,667 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,033 | Amount paid for insurance broker fees | 1308 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B2XN |
Policy instance | 3 |
Insurance contract or identification number | GLTD0B2XN | Number of Individuals Covered | 150 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $3,046 | 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 | No | 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 $30,930 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1032082 |
Policy instance | 2 |
Insurance contract or identification number | 1032082 | Number of Individuals Covered | 106 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $5,379 | Total amount of fees paid to insurance company | USD $985 | 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 | Welfare Benefit Premiums Paid to Carrier | USD $107,367 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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ASURIS NORTHWEST HEALTH (National Association of Insurance Commissioners NAIC id number: 47350 ) |
Policy contract number | 10017472 |
Policy instance | 4 |
Insurance contract or identification number | 10017472 | Number of Individuals Covered | 123 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $47,305 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,185,533 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUC0B2XN |
Policy instance | 5 |
Insurance contract or identification number | GUC0B2XN | Number of Individuals Covered | 47 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $3,216 | 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 | 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 $21,443 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0B2XN |
Policy instance | 6 |
Insurance contract or identification number | GVTL0B2XN | Number of Individuals Covered | 59 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $2,247 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,975 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30014645 |
Policy instance | 7 |
Insurance contract or identification number | 30014645 | Number of Individuals Covered | 95 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $1,248 | 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 | 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 $19,460 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B2XN |
Policy instance | 1 |
Insurance contract or identification number | GLUG0B2XN | Number of Individuals Covered | 150 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $321 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,212 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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