RICHARDSON SPORTS, INC. has sponsored the creation of one or more 401k plans.
Additional information about RICHARDSON SPORTS, INC.
Submission information for form 5500 for 401k plan OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D
401k plan membership statisitcs for OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D
| Measure | Date | Value |
|---|
| 2022: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 375 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 328 |
| 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 | 328 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 336 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 374 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
| 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 | 375 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 243 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 336 |
| 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 | 336 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 243 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 243 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 286 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 286 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 220 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 221 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 221 |
| 2016: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 220 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 220 |
| 2015: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 165 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 165 |
| 2014: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 165 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 165 |
| 2013: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 998 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 1,261 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 1,261 |
| 2012: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 949 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 998 |
| Total of all active and inactive participants | 2012-01-01 | 998 |
| Total participants | 2012-01-01 | 998 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| 2011: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 951 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 949 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 949 |
| 2010: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2010 401k membership |
|---|
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 951 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 951 |
| Total participants | 2010-01-01 | 951 |
| 2009: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 1,029 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 1,012 |
| Total of all active and inactive participants | 2009-01-01 | 1,012 |
| Total participants | 2009-01-01 | 1,012 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| 2022: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 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: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 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: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 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 funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 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 funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 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 funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | Yes |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | Yes |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | Yes |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: OREGON DENTAL SERVICE LONG-TERM DISABILITY, LIFE AND AD&D 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $283 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $283 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 2 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $688 | | Total amount of fees paid to insurance company | USD $282 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $688 | | Amount paid for insurance broker fees | 282 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 1 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,663 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,663 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 2 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,339 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,339 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $499 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,326 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $499 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 331 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $722 | | Total amount of fees paid to insurance company | USD $282 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $722 | | Amount paid for insurance broker fees | 282 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $11,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $6,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 2 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,845 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,845 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $571 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $571 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $616 | | Total amount of fees paid to insurance company | USD $191 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,073 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $616 | | Amount paid for insurance broker fees | 191 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 2 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,871 | | 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 | | Commission paid to Insurance Broker | USD $3,871 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $627 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $627 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,836 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $632 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $632 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 5 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $27,726 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,249,792 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,726 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 2 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,857 | | 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 $2,857 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $8,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 5 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $19,861 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,861 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $580 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $580 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $537 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $537 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2016-02-01 | | Insurance policy end date | 2017-01-31 | | Total amount of commissions paid to insurance broker | USD $473 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $473 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 5 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $14,911 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Were dividends or retroactive rate refunds paid in cash? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,911 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $7,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR271 |
| Policy instance | 2 |
| Insurance contract or identification number | OR271 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,012 | | 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 $2,012 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $407 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $407 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 1 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $16,880 | | 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 | 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 $742,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,880 | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $495 | | Total amount of fees paid to insurance company | USD $10 | | 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 | 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 $3,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $495 | | Amount paid for insurance broker fees | 10 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 2 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $84 | | Total amount of fees paid to insurance company | USD $2,961 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $2,497 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84 | | Amount paid for insurance broker fees | 2961 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI NORTHWEST |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 4 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 165 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $5,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENCE EMPLOYEE ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 4 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 165 | | 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 $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $5,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 2 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,294 | | Total amount of fees paid to insurance company | USD $756 | | 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 | 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 AND 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 $83,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,527 | | Amount paid for insurance broker fees | 756 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 1 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,976 | | 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 $595,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,033 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL6394941 |
| Policy instance | 5 |
| Insurance contract or identification number | ABL6394941 | | Number of Individuals Covered | 1174 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH | | 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 $0 | | 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 | 225309 |
| Policy instance | 4 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,630 | | Total amount of fees paid to insurance company | USD $477 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LONG TERM CARE | | 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 $38,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $478 | | Total amount of fees paid to insurance company | USD $107 | | 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 | 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 $3,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $478 | | Amount paid for insurance broker fees | 107 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CAMPBELL GALT AND NEWLANDS, INC. |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096437 |
| Policy instance | 1 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 1440 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $35,261 | | Total amount of fees paid to insurance company | USD $4,928 | | 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 | ACCIDENTAL DEATH AND 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 $394,237 | | 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 | 603428 |
| Policy instance | 2 |
| Insurance contract or identification number | 603428 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $515 | | Total amount of fees paid to insurance company | USD $62 | | 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 | 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 $2,875 | | 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 | 096438 |
| Policy instance | 3 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $12,478 | | Total amount of fees paid to insurance company | USD $2,376 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 $178,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300205 |
| Policy instance | 2 |
| Insurance contract or identification number | OR300205 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,319 | | 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 | 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 AND 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 $64,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD122954 |
| Policy instance | 3 |
| Insurance contract or identification number | LTD122954 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $437 | | 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 | 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 $2,914 | | 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 | 096437 |
| Policy instance | 1 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 1261 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $29,038 | | 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 | 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 $282,770 | | 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 | 225309 |
| Policy instance | 3 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $7,306 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LONG TERM CARE | | 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 $34,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 4 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 997 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-06-01 | | Total amount of commissions paid to insurance broker | USD $8 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH | | 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 $0 | | 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 | 096438 |
| Policy instance | 2 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $10,407 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $126,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 1 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 997 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $8 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096437 |
| Policy instance | 3 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 1261 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $29,038 | | 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 | ACCIDENTAL DEATH AND 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 $282,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,038 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096438 |
| Policy instance | 4 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $10,407 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $126,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,407 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 225309 |
| Policy instance | 5 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,306 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LONG TERM CARE | | 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 $34,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,306 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK009899 |
| Policy instance | 2 |
| Insurance contract or identification number | OK009899 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $2,676 | | Total amount of fees paid to insurance company | USD $120 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH AND 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 $21,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,676 | | Amount paid for insurance broker fees | 120 | | Additional information about fees paid to insurance broker | ENHANCED COMMISSION COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0032180 |
| Policy instance | 1 |
| Insurance contract or identification number | G0032180 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $10,503 | | 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 $527,686 | | 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 | 096438 |
| Policy instance | 2 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $9,673 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $117,252 | | 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 | 225309 |
| Policy instance | 3 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-06-01 | | Total amount of commissions paid to insurance broker | USD $9,288 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $43,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 4 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 998 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-06-01 | | Total amount of commissions paid to insurance broker | USD $460 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $3,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 105721 |
| Policy instance | 1 |
| Insurance contract or identification number | 105721 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $13,337 | | 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 $455,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 220681 |
| Policy instance | 2 |
| Insurance contract or identification number | 220681 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $3,317 | | 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 | 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 AND 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 $68,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK009899 |
| Policy instance | 2 |
| Insurance contract or identification number | OK009899 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $2,863 | | Total amount of fees paid to insurance company | USD $238 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH AND 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 $23,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,863 | | Amount paid for insurance broker fees | 238 | | Additional information about fees paid to insurance broker | ENHANCED COMMISSION COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 1 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 998 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $460 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $460 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 225309 |
| Policy instance | 5 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $8,576 | | Total amount of fees paid to insurance company | USD $1,022 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LONG TERM CARE | | 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 $41,312 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,576 | | Amount paid for insurance broker fees | 1022 | | Additional information about fees paid to insurance broker | ENHANCED COMMISSION COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096438 |
| Policy instance | 4 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $9,673 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $117,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,673 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 225309 |
| Policy instance | 6 |
| Insurance contract or identification number | 225309 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,921 | | Total amount of fees paid to insurance company | USD $185 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LONG TERM CARE | | 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 $14,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,921 | | Amount paid for insurance broker fees | 185 | | Additional information about fees paid to insurance broker | ENHANCED COMMISSION COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096437 |
| Policy instance | 1 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 998 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $33,302 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $321,152 | | 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 | 096437 |
| Policy instance | 3 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 998 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $33,302 | | 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 | ACCIDENTAL DEATH AND 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 $321,152 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,302 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 096437 |
| Policy instance | 3 |
| Insurance contract or identification number | 096437 | | Number of Individuals Covered | 949 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $31,300 | | 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 | ACCIDENTAL DEATH AND 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 $272,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 1 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 949 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $161 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK009899 |
| Policy instance | 2 |
| Insurance contract or identification number | OK009899 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,952 | | Total amount of fees paid to insurance company | USD $259 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH AND 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 $25,005 | | 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 | 096438 |
| Policy instance | 4 |
| Insurance contract or identification number | 096438 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $10,263 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $108,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK009899 |
| Policy instance | 4 |
| Insurance contract or identification number | OK009899 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2009-09-01 | | Insurance policy end date | 2010-08-31 | | Total amount of commissions paid to insurance broker | USD $3,007 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH AND 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 $26,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,007 | | Amount paid for insurance broker fees | 62 | | Additional information about fees paid to insurance broker | ENHANCED COMMISSION COMPENSATION | | Insurance broker organization code? | 0 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 32311 ) |
| Policy contract number | 307316 |
| Policy instance | 1 |
| Insurance contract or identification number | 307316 | | Number of Individuals Covered | 951 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $22,226 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $22,226 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 32311 ) |
| Policy contract number | 307316 |
| Policy instance | 2 |
| Insurance contract or identification number | 307316 | | Number of Individuals Covered | 951 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $26,194 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,194 | | Insurance broker organization code? | 3 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL634941 |
| Policy instance | 3 |
| Insurance contract or identification number | ABL634941 | | Number of Individuals Covered | 951 | | Insurance policy start date | 2009-06-01 | | Insurance policy end date | 2010-05-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
