TOYOTA OF ORANGE, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN
401k plan membership statisitcs for TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2023 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2023 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2023-06-30 | No |
| Was this plan covered by a fidelity bond | 2023-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2023-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2023-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2023-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2023-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2023-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2023-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2023-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2023-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2023-06-30 | No |
| Did the plan have assets held for investment | 2023-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2023-06-30 | No |
| 2022 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2022 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-06-30 | No |
| Was this plan covered by a fidelity bond | 2022-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2022-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-06-30 | No |
| Did the plan have assets held for investment | 2022-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-06-30 | No |
| 2021 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2021 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-06-30 | No |
| Was this plan covered by a fidelity bond | 2021-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2021-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-06-30 | No |
| Did the plan have assets held for investment | 2021-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-06-30 | No |
| 2020 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2020 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-06-30 | No |
| Was this plan covered by a fidelity bond | 2020-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2020-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-06-30 | No |
| Did the plan have assets held for investment | 2020-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-06-30 | No |
| 2019 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2019 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-06-30 | No |
| Was this plan covered by a fidelity bond | 2019-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2019-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2019-06-30 | No |
| Did the plan have assets held for investment | 2019-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-06-30 | No |
| 2018 : TOYOTA OF ORANGE, INC. FLEXIBLE BENEFIT PLAN 2018 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-06-30 | No |
| Was this plan covered by a fidelity bond | 2018-06-30 | No |
| If this is an individual account plan, was there a blackout period | 2018-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-06-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-06-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-06-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-06-30 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-06-30 | No |
| Did the plan have assets held for investment | 2018-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-06-30 | No |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0186902 |
| Policy instance | 3 |
| Insurance contract or identification number | 0186902 | | Number of Individuals Covered | 2429 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $198,552 | | Total amount of fees paid to insurance company | USD $130,870 | | Health Insurance Welfare Benefit | Yes | | 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 $146,534 | | Amount paid for insurance broker fees | 5400 | | Additional information about fees paid to insurance broker | 2022 Q3 BANNER HEALTH JOINT VENTURE INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0186902HNO |
| Policy instance | 2 |
| Insurance contract or identification number | 0186902HNO | | Number of Individuals Covered | 1585 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $482,748 | | Total amount of fees paid to insurance company | USD $20,000 | | Welfare Benefit Premiums Paid to Carrier | USD $8,776,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $249,650 | | Amount paid for insurance broker fees | 20000 | | Additional information about fees paid to insurance broker | 2022 Q3 GROW WITH US NEW BUSINESS INCENTIVE RISK |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16058 ) |
| Policy contract number | 0186902BH |
| Policy instance | 1 |
| Insurance contract or identification number | 0186902BH | | Number of Individuals Covered | 108 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $704,874 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 4 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 2229 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $3,340 | | Total amount of fees paid to insurance company | USD $1,287 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $22,262 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,340 | | Amount paid for insurance broker fees | 1287 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 5 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 617 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $42,842 | | Total amount of fees paid to insurance company | USD $15,192 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $288,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,842 | | Amount paid for insurance broker fees | 15192 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 384 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $49,149 | | Total amount of fees paid to insurance company | USD $16,664 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $330,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,149 | | Amount paid for insurance broker fees | 16664 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 618 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $69,535 | | Total amount of fees paid to insurance company | USD $21,149 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $466,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,535 | | Amount paid for insurance broker fees | 21149 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 1013 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $18,689 | | Total amount of fees paid to insurance company | USD $10,838 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $188,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,689 | | Amount paid for insurance broker fees | 10838 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064776 |
| Policy instance | 1 |
| Insurance contract or identification number | W0064776 | | Number of Individuals Covered | 1902 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $647,307 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,788,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $647,307 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-039 |
| Policy instance | 2 |
| Insurance contract or identification number | 908161-039 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $5,763 | | 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 $5,763 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-193 |
| Policy instance | 3 |
| Insurance contract or identification number | 908161-193 | | Number of Individuals Covered | 481 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $16,520 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,520 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 908161-199 |
| Policy instance | 4 |
| Insurance contract or identification number | 908161-199 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $11,870 | | 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 $11,870 | | Insurance broker organization code? | 5 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-771 |
| Policy instance | 5 |
| Insurance contract or identification number | 908161-771 | | Number of Individuals Covered | 817 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $43,716 | | 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 $43,716 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 553 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $34,734 | | Total amount of fees paid to insurance company | USD $12,482 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $231,557 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,734 | | Amount paid for insurance broker fees | 12482 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 375 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $44,289 | | Total amount of fees paid to insurance company | USD $15,789 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $295,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,289 | | Amount paid for insurance broker fees | 15789 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 9 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 623 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $69,919 | | Total amount of fees paid to insurance company | USD $20,430 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $466,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,919 | | Amount paid for insurance broker fees | 20430 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 10 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 961 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $18,276 | | Total amount of fees paid to insurance company | USD $9,260 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $182,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,276 | | Amount paid for insurance broker fees | 9260 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 1933 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $3,249 | | Total amount of fees paid to insurance company | USD $1,336 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $21,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,249 | | Amount paid for insurance broker fees | 1336 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 10 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 930 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $11,509 | | Total amount of fees paid to insurance company | USD $6,674 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $115,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,509 | | Amount paid for insurance broker fees | 6674 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064776 |
| Policy instance | 1 |
| Insurance contract or identification number | W0064776 | | Number of Individuals Covered | 1997 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $618,489 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,308,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $618,489 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-020 |
| Policy instance | 2 |
| Insurance contract or identification number | 908161-020 | | Number of Individuals Covered | 493 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $11,172 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,172 |
|
| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 908161-199 |
| Policy instance | 4 |
| Insurance contract or identification number | 908161-199 | | Number of Individuals Covered | 477 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $5,843 | | 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 $5,843 | | Insurance broker organization code? | 5 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-771 |
| Policy instance | 5 |
| Insurance contract or identification number | 908161-771 | | Number of Individuals Covered | 820 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $43,320 | | 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 $43,320 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 1955 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,133 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $20,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,133 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 543 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $26,453 | | Total amount of fees paid to insurance company | USD $10,225 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $176,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,453 | | Amount paid for insurance broker fees | 10225 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 333 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $38,680 | | Total amount of fees paid to insurance company | USD $14,717 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $257,869 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,680 | | Amount paid for insurance broker fees | 14717 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 9 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 598 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $67,232 | | Total amount of fees paid to insurance company | USD $19,439 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $448,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $67,232 | | Amount paid for insurance broker fees | 19439 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-193 |
| Policy instance | 3 |
| Insurance contract or identification number | 908161-193 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $18,538 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $169,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,538 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 908161-199 |
| Policy instance | 4 |
| Insurance contract or identification number | 908161-199 | | Number of Individuals Covered | 463 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $5,130 | | 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 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-193 |
| Policy instance | 3 |
| Insurance contract or identification number | 908161-193 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $17,468 | | 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 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-140 |
| Policy instance | 2 |
| Insurance contract or identification number | 908161-140 | | Number of Individuals Covered | 471 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $9,635 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064776 |
| Policy instance | 1 |
| Insurance contract or identification number | W0064776 | | Number of Individuals Covered | 1936 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $601,946 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,742,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-771 |
| Policy instance | 5 |
| Insurance contract or identification number | 908161-771 | | Number of Individuals Covered | 736 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $35,023 | | 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 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 6 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 1816 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,967 | | Total amount of fees paid to insurance company | USD $1,001 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $19,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 10 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 861 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $11,091 | | Total amount of fees paid to insurance company | USD $1,711 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $110,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 9 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 563 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $63,292 | | Total amount of fees paid to insurance company | USD $8,750 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $421,946 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 317 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $36,687 | | Total amount of fees paid to insurance company | USD $8,750 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $244,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 523 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $25,980 | | Total amount of fees paid to insurance company | USD $6,242 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $173,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064776 |
| Policy instance | 1 |
| Insurance contract or identification number | W0064776 | | Number of Individuals Covered | 1981 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $568,101 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,472,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $568,101 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30780-1036 |
| Policy instance | 2 |
| Insurance contract or identification number | 30780-1036 | | Number of Individuals Covered | 1500 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $10,295 | | Total amount of fees paid to insurance company | USD $0 | | Vision 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 $10,295 | | Insurance broker organization code? | 5 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-140 |
| Policy instance | 3 |
| Insurance contract or identification number | 908161-140 | | Number of Individuals Covered | 498 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $5,597 | | 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 $5,597 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-193 |
| Policy instance | 4 |
| Insurance contract or identification number | 908161-193 | | Number of Individuals Covered | 606 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $18,093 | | 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 $18,093 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 908161-199 |
| Policy instance | 5 |
| Insurance contract or identification number | 908161-199 | | Number of Individuals Covered | 506 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $9,737 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,737 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-771 |
| Policy instance | 6 |
| Insurance contract or identification number | 908161-771 | | Number of Individuals Covered | 713 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $33,379 | | 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 $33,379 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 7 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 1805 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,134 | | Total amount of fees paid to insurance company | USD $1,879 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $20,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,134 | | Amount paid for insurance broker fees | 1879 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 8 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 517 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $26,811 | | Total amount of fees paid to insurance company | USD $10,705 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $178,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,811 | | Amount paid for insurance broker fees | 10705 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 9 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 381 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $39,470 | | Total amount of fees paid to insurance company | USD $15,182 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $263,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,470 | | Amount paid for insurance broker fees | 15182 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AT3U |
| Policy instance | 10 |
| Insurance contract or identification number | G000AT3U | | Number of Individuals Covered | 565 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $60,010 | | Total amount of fees paid to insurance company | USD $19,703 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $400,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,010 | | Amount paid for insurance broker fees | 19703 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-599 |
| Policy instance | 10 |
| Insurance contract or identification number | 908161-599 | | Number of Individuals Covered | 734 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $32,471 | | Total amount of fees paid to insurance company | USD $1,630 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
| Policy contract number | 908161-200 |
| Policy instance | 9 |
| Insurance contract or identification number | 908161-200 | | Number of Individuals Covered | 574 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $5,614 | | Total amount of fees paid to insurance company | USD $284 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-193 |
| Policy instance | 8 |
| Insurance contract or identification number | 908161-193 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $17,155 | | Total amount of fees paid to insurance company | USD $857 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROAT3U |
| Policy instance | 2 |
| Insurance contract or identification number | GUPROAT3U | | Number of Individuals Covered | 368 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $38,503 | | Total amount of fees paid to insurance company | USD $15,544 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AT3U |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AT3U | | Number of Individuals Covered | 1612 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $4,700 | | Total amount of fees paid to insurance company | USD $1,969 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AT3U |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0AT3U | | Number of Individuals Covered | 550 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $27,136 | | Total amount of fees paid to insurance company | USD $10,816 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AT3U |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0AT3U | | Number of Individuals Covered | 555 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $65,694 | | Total amount of fees paid to insurance company | USD $19,750 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064776 |
| Policy instance | 5 |
| Insurance contract or identification number | W0064776 | | Number of Individuals Covered | 1988 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $554,978 | | Total amount of fees paid to insurance company | USD $154 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30780-1036 |
| Policy instance | 6 |
| Insurance contract or identification number | 30780-1036 | | Number of Individuals Covered | 1534 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $10,772 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 908161-772 |
| Policy instance | 7 |
| Insurance contract or identification number | 908161-772 | | Number of Individuals Covered | 524 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $10,226 | | Total amount of fees paid to insurance company | USD $514 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AT3U |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0AT3U | | Number of Individuals Covered | 562 | | Total amount of commissions paid to insurance broker | USD $24,545 | | Total amount of fees paid to insurance company | USD $6,790 | | Temporary Disability 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 $24,545 | | Amount paid for insurance broker fees | 6790 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 0218773 |
| Policy instance | 6 |
| Insurance contract or identification number | 0218773 | | Number of Individuals Covered | 623 | | Total amount of commissions paid to insurance broker | USD $40,696 | | 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 $40,696 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES, INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30780-1036 |
| Policy instance | 7 |
| Insurance contract or identification number | 30780-1036 | | Number of Individuals Covered | 1715 | | Total amount of commissions paid to insurance broker | USD $10,612 | | Vision 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 $10,612 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR PEDERSON |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROAT3U |
| Policy instance | 2 |
| Insurance contract or identification number | GUPROAT3U | | Number of Individuals Covered | 439 | | Total amount of commissions paid to insurance broker | USD $41,417 | | Total amount of fees paid to insurance company | USD $11,322 | | Long Term Disability 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 $41,417 | | Amount paid for insurance broker fees | 11322 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AT3U |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AT3U | | Number of Individuals Covered | 1738 | | Total amount of commissions paid to insurance broker | USD $2,385 | | Total amount of fees paid to insurance company | USD $676 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,385 | | Amount paid for insurance broker fees | 676 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905228 |
| Policy instance | 5 |
| Insurance contract or identification number | 905228 | | Number of Individuals Covered | 2097 | | Total amount of commissions paid to insurance broker | USD $523,864 | | 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 $523,864 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR INS AGENCY INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AT3U |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0AT3U | | Number of Individuals Covered | 675 | | Total amount of commissions paid to insurance broker | USD $66,843 | | Total amount of fees paid to insurance company | USD $13,015 | | Life 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 $66,843 | | Amount paid for insurance broker fees | 13015 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AT3U |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0AT3U | | Number of Individuals Covered | 687 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $60,171 | | Total amount of fees paid to insurance company | USD $33,491 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $401,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,171 | | Amount paid for insurance broker fees | 33491 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AT3U |
| Policy instance | 5 |
| Insurance contract or identification number | GUC0AT3U | | Number of Individuals Covered | 539 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $22,139 | | Total amount of fees paid to insurance company | USD $11,273 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $147,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,139 | | Amount paid for insurance broker fees | 11273 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROAT3U |
| Policy instance | 4 |
| Insurance contract or identification number | GUPROAT3U | | Number of Individuals Covered | 438 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $37,560 | | Total amount of fees paid to insurance company | USD $18,478 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $250,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,560 | | Amount paid for insurance broker fees | 18478 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AT3U |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AT3U | | Number of Individuals Covered | 1741 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $2,061 | | Total amount of fees paid to insurance company | USD $936 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,061 | | Amount paid for insurance broker fees | 936 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR & ASSOCIATES INC |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95003 ) |
| Policy contract number | 0847063 |
| Policy instance | 2 |
| Insurance contract or identification number | 0847063 | | Number of Individuals Covered | 1528 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $395,266 | | Welfare Benefit Premiums Paid to Carrier | USD $7,025,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $395,266 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY BOLWAR INS AGENCY INC |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276538 |
| Policy instance | 1 |
| Insurance contract or identification number | 276538 | | Number of Individuals Covered | 1658 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $28,772 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $504,230 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,218 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOC INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 121 | | Total amount of commissions paid to insurance broker | USD $9,420 | | Total amount of fees paid to insurance company | USD $11,929 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 11929 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $9,420 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400003002 |
| Policy instance | 5 |
| Insurance contract or identification number | 000400003002 | | Number of Individuals Covered | 422 | | Total amount of commissions paid to insurance broker | USD $35,893 | | Total amount of fees paid to insurance company | USD $10,126 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $239,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,893 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 10126 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | DULEY BOLWAR INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143049 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010143049 | | Number of Individuals Covered | 415 | | Total amount of commissions paid to insurance broker | USD $10,986 | | Total amount of fees paid to insurance company | USD $3,390 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $73,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,986 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3390 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | DULEY BOLWAR INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143048 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010143048 | | Number of Individuals Covered | 12 | | Total amount of commissions paid to insurance broker | USD $38 | | Total amount of fees paid to insurance company | USD $534 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $384 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 534 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $38 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276538 |
| Policy instance | 1 |
| Insurance contract or identification number | 276538 | | Number of Individuals Covered | 1480 | | Total amount of commissions paid to insurance broker | USD $24,571 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $418,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,686 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0847063 |
| Policy instance | 7 |
| Insurance contract or identification number | 0847063 | | Number of Individuals Covered | 1194 | | Total amount of commissions paid to insurance broker | USD $64,261 | | Total amount of fees paid to insurance company | USD $2,354 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $723,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,261 | | Amount paid for insurance broker fees | 2354 | | Additional information about fees paid to insurance broker | GI CROSS SELL BONUS (TERM LIFE, AD&D AND SUP TERM LIFE) | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143362 |
| Policy instance | 6 |
| Insurance contract or identification number | 000010143362 | | Number of Individuals Covered | 96 | | Total amount of commissions paid to insurance broker | USD $7,930 | | Total amount of fees paid to insurance company | USD $2,687 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $52,867 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,930 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2687 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | DULEY BOLWAR INS AGENCY INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143362 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010143362 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $8,740 | | Total amount of fees paid to insurance company | USD $1,499 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $58,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1499 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $8,740 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400003002 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400003002 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $34,638 | | Total amount of fees paid to insurance company | USD $4,657 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $230,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4657 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $34,638 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 643 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $48,926 | | Total amount of fees paid to insurance company | USD $6,625 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $326,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6625 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $48,926 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143049 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010143049 | | Number of Individuals Covered | 402 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $11,501 | | Total amount of fees paid to insurance company | USD $1,669 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $76,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1669 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $11,501 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276538 |
| Policy instance | 7 |
| Insurance contract or identification number | 276538 | | Number of Individuals Covered | 1548 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $35,481 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $397,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,916 | | Insurance broker organization code? | 3 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC. |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | |
| Policy instance | 1 |
| Number of Individuals Covered | 919 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $231,847 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,610,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $231,847 | | Insurance broker organization code? | 3 | | Insurance broker name | DULEY-BOLWAR & ASSOCIATES INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143048 |
| Policy instance | 6 |
| Insurance contract or identification number | 000010143048 | | Number of Individuals Covered | 1076 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,315 | | Total amount of fees paid to insurance company | USD $349 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 349 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,315 | | Insurance broker name | DBG BENEFIT SOLUTIONS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143362 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010143362 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $9,202 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $61,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | HS4955/944809 |
| Policy instance | 9 |
| Insurance contract or identification number | HS4955/944809 | | Number of Individuals Covered | 908 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $242,449 | | Total amount of fees paid to insurance company | USD $208 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,065,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276538 |
| Policy instance | 8 |
| Insurance contract or identification number | 276538 | | Number of Individuals Covered | 796 | | Total amount of commissions paid to insurance broker | USD $18,280 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $347,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-036841 |
| Policy instance | 7 |
| Insurance contract or identification number | 010-036841 | | Number of Individuals Covered | 484 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $5,702 | | Total amount of fees paid to insurance company | USD $1,681 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $114,027 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143049 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010143049 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $10,315 | | Other welfare benefits provided | WEEKLY INCOME | | Welfare Benefit Premiums Paid to Carrier | USD $68,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 742488 |
| Policy instance | 1 |
| Insurance contract or identification number | 742488 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $85,668 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,384,731 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010143048 |
| Policy instance | 6 |
| Insurance contract or identification number | 000010143048 | | Number of Individuals Covered | 1268 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,475 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400003002 |
| Policy instance | 3 |
| Insurance contract or identification number | 000400003002 | | Number of Individuals Covered | 428 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $29,044 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $193,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000400001000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000400001000 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $40,283 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $268,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | H54955/944809 |
| Policy instance | 6 |
| Insurance contract or identification number | H54955/944809 | | Number of Individuals Covered | 868 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $237,684 | | Total amount of fees paid to insurance company | USD $159 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,934,159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NP5291 |
| Policy instance | 5 |
| Insurance contract or identification number | NP5291 | | Number of Individuals Covered | 818 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $18,838 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $288,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00447735 |
| Policy instance | 3 |
| Insurance contract or identification number | 00447735 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $4,331 | | Total amount of fees paid to insurance company | USD $3,085 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $86,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0105705 |
| Policy instance | 2 |
| Insurance contract or identification number | 0105705 | | Number of Individuals Covered | 1240 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $20,936 | | Total amount of fees paid to insurance company | USD $2,511 | | 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 & 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 $214,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | AZ/AC 1293 |
| Policy instance | 1 |
| Insurance contract or identification number | AZ/AC 1293 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $74,160 | | 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 $1,507,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAQK |
| Policy instance | 4 |
| Insurance contract or identification number | G000AAQK | | Number of Individuals Covered | 428 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $38,241 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $301,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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