ONTARIO REFRIGERATION SERVICE, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ONTARIO REFRIGERATION WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 255 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 0 |
| Total of all active and inactive participants | 2022-12-01 | 255 |
| Number of employers contributing to the scheme | 2022-12-01 | 0 |
| 2021: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 282 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 221 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 224 |
| Number of employers contributing to the scheme | 2021-12-01 | 0 |
| 2020: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 184 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 185 |
| Number of employers contributing to the scheme | 2020-12-01 | 0 |
| 2019: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 188 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 189 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2018: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 165 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 166 |
| Number of employers contributing to the scheme | 2018-12-01 | 0 |
| 2017: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 408 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 161 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 161 |
| Number of employers contributing to the scheme | 2017-12-01 | 0 |
| 2016: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 445 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 173 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 175 |
| 2015: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 392 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 163 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 163 |
| 2014: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 166 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 173 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 173 |
| 2013: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 166 |
| Number of retired or separated participants receiving benefits | 2013-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-01 | 0 |
| Total of all active and inactive participants | 2013-12-01 | 166 |
| 2012: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 151 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 151 |
| 2011: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 131 |
| Number of retired or separated participants receiving benefits | 2011-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-01 | 0 |
| Total of all active and inactive participants | 2011-12-01 | 131 |
| 2010: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 202 |
| Number of retired or separated participants receiving benefits | 2010-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-01 | 0 |
| Total of all active and inactive participants | 2010-12-01 | 202 |
| 2009: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 206 |
| Number of retired or separated participants receiving benefits | 2009-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-01 | 0 |
| Total of all active and inactive participants | 2009-12-01 | 206 |
| 2008: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-12-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-12-01 | 147 |
| Number of retired or separated participants receiving benefits | 2008-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-12-01 | 0 |
| Total of all active and inactive participants | 2008-12-01 | 147 |
| 2022: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | Yes |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: ONTARIO REFRIGERATION WELFARE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-12-01 | Type of plan entity | Single employer plan |
| 2008-12-01 | Submission has been amended | No |
| 2008-12-01 | This submission is the final filing | No |
| 2008-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-12-01 | Plan is a collectively bargained plan | No |
| 2008-12-01 | Plan funding arrangement – Insurance | Yes |
| 2008-12-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 255 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $9,995 | | Total amount of fees paid to insurance company | USD $6,585 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $99,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,809 | | Amount paid for insurance broker fees | 5874 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16059 ) |
| Policy contract number | 144689HNOBH |
| Policy instance | 4 |
| Insurance contract or identification number | 144689HNOBH | | Number of Individuals Covered | 53 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $10,270 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $280,830 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,343 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144689HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 144689HNO | | Number of Individuals Covered | 318 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $35,257 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,689,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,477 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $3,146 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,334 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 144689 |
| Policy instance | 1 |
| Insurance contract or identification number | 144689 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $13,554 | | Total amount of fees paid to insurance company | USD $148 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $654,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,384 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 144689 |
| Policy instance | 1 |
| Insurance contract or identification number | 144689 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $16,773 | | Total amount of fees paid to insurance company | USD $14,520 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $484,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,773 | | Amount paid for insurance broker fees | 14520 | | Additional information about fees paid to insurance broker | 2021 PINNACLE MEDICAL RETENTION INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $2,522 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,522 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144689HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 144689HNO | | Number of Individuals Covered | 314 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $52,312 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,484,812 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,312 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 230 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $9,333 | | Total amount of fees paid to insurance company | USD $5,819 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $93,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,333 | | Amount paid for insurance broker fees | 5819 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16059 ) |
| Policy contract number | 144689HNOBH |
| Policy instance | 4 |
| Insurance contract or identification number | 144689HNOBH | | Number of Individuals Covered | 57 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $10,897 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $304,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,897 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 144689 |
| Policy instance | 1 |
| Insurance contract or identification number | 144689 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $13,601 | | Total amount of fees paid to insurance company | USD $6,900 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $323,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,601 | | Amount paid for insurance broker fees | 6900 | | Additional information about fees paid to insurance broker | 2020 PINNACLE MEDICAL RETENTION INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 191 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $9,087,411 | | Total amount of fees paid to insurance company | USD $4,979 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $83,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,411 | | Amount paid for insurance broker fees | 4429 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,254 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,254 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH INC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144689HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 144689HNO | | Number of Individuals Covered | 305 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $53,094 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,388,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,094 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16059 ) |
| Policy contract number | 144689HNOBH |
| Policy instance | 4 |
| Insurance contract or identification number | 144689HNOBH | | Number of Individuals Covered | 61 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $11,169 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $286,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,169 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 196 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $8,289 | | Total amount of fees paid to insurance company | USD $5,281 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $82,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,376 | | Amount paid for insurance broker fees | 4657 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144689HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 144689HNO | | Number of Individuals Covered | 338 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $46,869 | | Total amount of fees paid to insurance company | USD $1,780 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,230,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,869 | | Amount paid for insurance broker fees | 1780 | | Additional information about fees paid to insurance broker | 2019 PREMIER PRODUCER PROGRAM- MEDICAL NEW BUSINESS RISK | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16059 ) |
| Policy contract number | 144689HNOBH |
| Policy instance | 4 |
| Insurance contract or identification number | 144689HNOBH | | Number of Individuals Covered | 58 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $8,074 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $219,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,074 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $2,177 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,177 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 144689 |
| Policy instance | 1 |
| Insurance contract or identification number | 144689 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $11,095 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $290,604 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,095 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 190 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $8,846,561 | | Total amount of fees paid to insurance company | USD $6,244,459 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $74,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,561 | | Amount paid for insurance broker fees | 4459 | | 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 | W0067533 |
| Policy instance | 1 |
| Insurance contract or identification number | W0067533 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $91,283 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,821,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 91283 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES BONUS MISC. | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $2,162 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,162 | | Amount paid for insurance broker fees | 0 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 188 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $7,258 | | Total amount of fees paid to insurance company | USD $5,017 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $72,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $1,924 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,484 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 906642 |
| Policy instance | 1 |
| Insurance contract or identification number | 906642 | | Number of Individuals Covered | 413 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $82,586 | | Total amount of fees paid to insurance company | USD $18,732 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,879,233 | | 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 | GLUG0AK9T |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 173 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $6,668 | | Total amount of fees paid to insurance company | USD $3,049 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $66,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,846 | | Amount paid for insurance broker fees | 2654 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $1,844 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,844 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0002351 |
| Policy instance | 1 |
| Insurance contract or identification number | W0002351 | | Number of Individuals Covered | 396 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $73,646 | | Total amount of fees paid to insurance company | USD $6,046 | | 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 $1,472,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73,646 | | Amount paid for insurance broker fees | 6046 | | Additional information about fees paid to insurance broker | BONUS OVERRIDE ALLOCATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 166 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $780 | | Total amount of fees paid to insurance company | USD $333 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,795 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $780 | | Amount paid for insurance broker fees | 333 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $1,583 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,583 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0002351 |
| Policy instance | 1 |
| Insurance contract or identification number | W0002351 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $66,167 | | Total amount of fees paid to insurance company | USD $63 | | 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 $1,289,751 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,167 | | Amount paid for insurance broker fees | 63 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AK9T |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0AK9T | | Number of Individuals Covered | 88 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $4,978 | | 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 $49,787 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,978 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 75605 |
| Policy instance | 2 |
| Insurance contract or identification number | 75605 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | 2024338 |
| Policy instance | 1 |
| Insurance contract or identification number | 2024338 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $59,333 | | 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 $1,152,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,333 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $667 | | Total amount of fees paid to insurance company | USD $228 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $667 | | Amount paid for insurance broker fees | 228 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AK9T |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AK9T | | Number of Individuals Covered | 131 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $658 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,444 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $658 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | 2024338 |
| Policy instance | 1 |
| Insurance contract or identification number | 2024338 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $54,321 | | Total amount of fees paid to insurance company | USD $8,930 | | 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 $1,086,423 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,321 | | Amount paid for insurance broker fees | 8930 | | Additional information about fees paid to insurance broker | BONUS OVERIDE ALLOCATION | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US413865 |
| Policy instance | 1 |
| Insurance contract or identification number | US413865 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $38,894 | | 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 $782,904 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,894 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| AETNA LIFE INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 806119 |
| Policy instance | 2 |
| Insurance contract or identification number | 806119 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $9,346 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $196,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,346 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US413865 |
| Policy instance | 1 |
| Insurance contract or identification number | US413865 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $31,799 | | Total amount of fees paid to insurance company | USD $13,200 | | 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 $694,740 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,799 | | Amount paid for insurance broker fees | 13200 | | Additional information about fees paid to insurance broker | NEW BUSINESS MEDICAL BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| AETNA LIFE INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 806119 |
| Policy instance | 2 |
| Insurance contract or identification number | 806119 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $8,939 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $176,200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,939 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL INS. SVCES., INC. |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL163218 |
| Policy instance | 2 |
| Insurance contract or identification number | GL163218 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2008-12-01 | | Insurance policy end date | 2009-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 525268 |
| Policy instance | 1 |
| Insurance contract or identification number | 525268 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2008-12-01 | | Insurance policy end date | 2009-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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