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KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan NameKAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number 501

KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

KAREN KANE, INC. has sponsored the creation of one or more 401k plans.

Company Name:KAREN KANE, INC.
Employer identification number (EIN):953579007
NAIC Classification:315240
NAIC Description:Women's, Girls', and Infants' Cut and Sew Apparel Manufacturing

Additional information about KAREN KANE, INC.

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 1981-03-18
Company Identification Number: C1039222
Legal Registered Office Address: 1900 Avenue Of The Stars Ste 2300

Los Angeles
United States of America (USA)
90067

More information about KAREN KANE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-08-01
5012021-08-01LONNIE KANE2022-12-22
5012020-08-01LONNIE KANE2022-02-23
5012019-08-01
5012018-08-01
5012017-08-01LONNIE KANE LONNIE KANE2019-02-22
5012016-08-01LONNIE KANE LONNIE KANE2018-01-03
5012015-08-01LONNIE KANE LONNIE KANE2016-12-23
5012014-08-01LONNIE KANE LONNIE KANE2016-02-22
5012013-08-01LONNIE KANE LONNIE KANE2014-12-01
5012012-08-01LONNIE KANE LONNIE KANE2014-01-08
5012011-11-01LONNIE KANE LONNIE KANE2012-10-30
5012009-11-01LONNIE KANE LONNIE KANE2011-02-04
5012008-11-01

Plan Statistics for KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-08-01128
Total number of active participants reported on line 7a of the Form 55002022-08-01132
Number of retired or separated participants receiving benefits2022-08-011
Number of other retired or separated participants entitled to future benefits2022-08-010
Total of all active and inactive participants2022-08-01133
2021: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-08-01113
Total number of active participants reported on line 7a of the Form 55002021-08-01127
Number of retired or separated participants receiving benefits2021-08-011
Number of other retired or separated participants entitled to future benefits2021-08-010
Total of all active and inactive participants2021-08-01128
2020: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01109
Total number of active participants reported on line 7a of the Form 55002020-08-01113
Number of retired or separated participants receiving benefits2020-08-010
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01113
2019: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01142
Total number of active participants reported on line 7a of the Form 55002019-08-01109
Number of retired or separated participants receiving benefits2019-08-013
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01112
2018: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01151
Total number of active participants reported on line 7a of the Form 55002018-08-01142
Number of retired or separated participants receiving benefits2018-08-010
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01142
2017: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01146
Total number of active participants reported on line 7a of the Form 55002017-08-01151
Number of retired or separated participants receiving benefits2017-08-010
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01151
2016: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01148
Total number of active participants reported on line 7a of the Form 55002016-08-01146
Number of retired or separated participants receiving benefits2016-08-010
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01146
2015: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01148
Total number of active participants reported on line 7a of the Form 55002015-08-01148
Number of retired or separated participants receiving benefits2015-08-010
Number of other retired or separated participants entitled to future benefits2015-08-010
Total of all active and inactive participants2015-08-01148
2014: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01147
Total number of active participants reported on line 7a of the Form 55002014-08-01148
Number of retired or separated participants receiving benefits2014-08-010
Number of other retired or separated participants entitled to future benefits2014-08-010
Total of all active and inactive participants2014-08-01148
2013: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01147
Total number of active participants reported on line 7a of the Form 55002013-08-01147
Number of other retired or separated participants entitled to future benefits2013-08-010
Total of all active and inactive participants2013-08-01147
2012: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01134
Total number of active participants reported on line 7a of the Form 55002012-08-01134
Number of retired or separated participants receiving benefits2012-08-010
Number of other retired or separated participants entitled to future benefits2012-08-010
Total of all active and inactive participants2012-08-01134
2011: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01128
Total number of active participants reported on line 7a of the Form 55002011-11-01128
Number of retired or separated participants receiving benefits2011-11-010
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01128
2009: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-11-01141
Total number of active participants reported on line 7a of the Form 55002009-11-01144
Number of retired or separated participants receiving benefits2009-11-010
Number of other retired or separated participants entitled to future benefits2009-11-010
Total of all active and inactive participants2009-11-01144
Total participants2009-11-010

Form 5500 Responses for KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN

2022: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-08-01Type of plan entitySingle employer plan
2022-08-01Submission has been amendedNo
2022-08-01This submission is the final filingNo
2022-08-01This return/report is a short plan year return/report (less than 12 months)No
2022-08-01Plan is a collectively bargained planNo
2022-08-01Plan funding arrangement – InsuranceYes
2022-08-01Plan funding arrangement – General assets of the sponsorYes
2022-08-01Plan benefit arrangement – InsuranceYes
2022-08-01Plan benefit arrangement – General assets of the sponsorYes
2021: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Submission has been amendedNo
2021-08-01This submission is the final filingNo
2021-08-01This return/report is a short plan year return/report (less than 12 months)No
2021-08-01Plan is a collectively bargained planNo
2021-08-01Plan funding arrangement – InsuranceYes
2021-08-01Plan funding arrangement – General assets of the sponsorYes
2021-08-01Plan benefit arrangement – InsuranceYes
2021-08-01Plan benefit arrangement – General assets of the sponsorYes
2020: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)No
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan funding arrangement – General assets of the sponsorYes
2020-08-01Plan benefit arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – General assets of the sponsorYes
2019: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan funding arrangement – General assets of the sponsorYes
2019-08-01Plan benefit arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – General assets of the sponsorYes
2018: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Submission has been amendedNo
2018-08-01This submission is the final filingNo
2018-08-01This return/report is a short plan year return/report (less than 12 months)No
2018-08-01Plan is a collectively bargained planNo
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan funding arrangement – General assets of the sponsorYes
2018-08-01Plan benefit arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – General assets of the sponsorYes
2017: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan funding arrangement – General assets of the sponsorYes
2017-08-01Plan benefit arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – General assets of the sponsorYes
2016: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan funding arrangement – General assets of the sponsorYes
2016-08-01Plan benefit arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – General assets of the sponsorYes
2015: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Submission has been amendedNo
2015-08-01This submission is the final filingNo
2015-08-01This return/report is a short plan year return/report (less than 12 months)No
2015-08-01Plan is a collectively bargained planNo
2015-08-01Plan funding arrangement – InsuranceYes
2015-08-01Plan funding arrangement – General assets of the sponsorYes
2015-08-01Plan benefit arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – General assets of the sponsorYes
2014: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Submission has been amendedNo
2014-08-01This submission is the final filingNo
2014-08-01This return/report is a short plan year return/report (less than 12 months)No
2014-08-01Plan is a collectively bargained planNo
2014-08-01Plan funding arrangement – InsuranceYes
2014-08-01Plan funding arrangement – General assets of the sponsorYes
2014-08-01Plan benefit arrangement – InsuranceYes
2014-08-01Plan benefit arrangement – General assets of the sponsorYes
2013: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)No
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – InsuranceYes
2013-08-01Plan funding arrangement – General assets of the sponsorYes
2013-08-01Plan benefit arrangement – InsuranceYes
2013-08-01Plan benefit arrangement – General assets of the sponsorYes
2012: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Submission has been amendedNo
2012-08-01This submission is the final filingNo
2012-08-01This return/report is a short plan year return/report (less than 12 months)No
2012-08-01Plan is a collectively bargained planNo
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan funding arrangement – General assets of the sponsorYes
2012-08-01Plan benefit arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – General assets of the sponsorYes
2011: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedNo
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)Yes
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan funding arrangement – General assets of the sponsorYes
2011-11-01Plan benefit arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – General assets of the sponsorYes
2009: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-11-01Type of plan entitySingle employer plan
2009-11-01Submission has been amendedNo
2009-11-01This submission is the final filingNo
2009-11-01This return/report is a short plan year return/report (less than 12 months)No
2009-11-01Plan is a collectively bargained planNo
2009-11-01Plan funding arrangement – InsuranceYes
2009-11-01Plan funding arrangement – General assets of the sponsorYes
2009-11-01Plan benefit arrangement – InsuranceYes
2009-11-01Plan benefit arrangement – General assets of the sponsorYes
2008: KAREN KANE, INC. EMPLOYEE WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-11-01Type of plan entitySingle employer plan
2008-11-01Submission has been amendedNo
2008-11-01This submission is the final filingNo
2008-11-01This return/report is a short plan year return/report (less than 12 months)No
2008-11-01Plan is a collectively bargained planNo

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5946110
Policy instance 3
Insurance contract or identification number5946110
Number of Individuals Covered183
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $12,265
Total amount of fees paid to insurance companyUSD $1,660
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $90,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,374
Amount paid for insurance broker fees798
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION/NON-MONETARY COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00356021
Policy instance 2
Insurance contract or identification number00356021
Number of Individuals Covered121
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $24,726
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $195,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,726
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BRHH
Policy instance 1
Insurance contract or identification numberG000BRHH
Number of Individuals Covered132
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $8,882
Total amount of fees paid to insurance companyUSD $4,873
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, CRITICAL ILLNESS & CANCER, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $59,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,882
Amount paid for insurance broker fees2737
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5946110
Policy instance 3
Insurance contract or identification number5946110
Number of Individuals Covered177
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $7,207
Total amount of fees paid to insurance companyUSD $2,174
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $67,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,207
Amount paid for insurance broker fees2174
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION/NON-MONETARY COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00356021
Policy instance 2
Insurance contract or identification number00356021
Number of Individuals Covered127
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $23,813
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $169,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,813
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BRHH
Policy instance 1
Insurance contract or identification numberG000BRHH
Number of Individuals Covered127
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $9,127
Total amount of fees paid to insurance companyUSD $4,638
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $60,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,127
Amount paid for insurance broker fees2446
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BRHH
Policy instance 1
Insurance contract or identification numberG000BRHH
Number of Individuals Covered113
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $7,054
Total amount of fees paid to insurance companyUSD $2,242
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,054
Amount paid for insurance broker fees583
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00356021
Policy instance 2
Insurance contract or identification number00356021
Number of Individuals Covered113
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $21,663
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $132,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,663
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5946110
Policy instance 3
Insurance contract or identification number5946110
Number of Individuals Covered168
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $5,559
Total amount of fees paid to insurance companyUSD $1,497
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $60,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,559
Amount paid for insurance broker fees1497
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION/NON-MONETARY COMPENSATION
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number920861
Policy instance 1
Insurance contract or identification number920861
Number of Individuals Covered193
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $8,412
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $84,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,330
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number618869
Policy instance 2
Insurance contract or identification number618869
Number of Individuals Covered12
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,750
Total amount of fees paid to insurance companyUSD $89
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $741
Insurance broker organization code?3
Amount paid for insurance broker fees89
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0401600000
Policy instance 4
Insurance contract or identification number0401600000
Number of Individuals Covered25
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $2,276
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $11,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,527
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number651797
Policy instance 3
Insurance contract or identification number651797
Number of Individuals Covered43
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $2,858
Total amount of fees paid to insurance companyUSD $166
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $17,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,180
Insurance broker organization code?3
Amount paid for insurance broker fees166
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0401600000
Policy instance 5
Insurance contract or identification number0401600000
Number of Individuals Covered52
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,211
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $12,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $813
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 6
Insurance contract or identification numberSOK602194
Number of Individuals Covered109
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $99
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $99
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 7
Insurance contract or identification numberSGM603446
Number of Individuals Covered109
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $596
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $596
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number040160000
Policy instance 1
Insurance contract or identification number040160000
Number of Individuals Covered65
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,997
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $16,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,053
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B32M
Policy instance 2
Insurance contract or identification numberGVTL0B32M
Number of Individuals Covered50
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $4,458
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLIFE AND A.D. & D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $29,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,229
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 8
Insurance contract or identification numberSOK602194
Number of Individuals Covered138
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $161
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $161
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 7
Insurance contract or identification numberSGM603446
Number of Individuals Covered138
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $966
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $966
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0B32M
Policy instance 6
Insurance contract or identification numberGUC 0B32M
Number of Individuals Covered19
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $2,522
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedVOLUNATRY SHORT TERM DISABILTY
Welfare Benefit Premiums Paid to CarrierUSD $16,814
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,261
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00356021
Policy instance 5
Insurance contract or identification number00356021
Number of Individuals Covered138
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $33,496
Total amount of fees paid to insurance companyUSD $3,000
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $171,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,496
Amount paid for insurance broker fees3000
Additional information about fees paid to insurance brokerINCENTIVE COMPENSATION
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0401600000
Policy instance 4
Insurance contract or identification number0401600000
Number of Individuals Covered31
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,128
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER - CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $16,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,122
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number920861
Policy instance 3
Insurance contract or identification number920861
Number of Individuals Covered142
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $8,472
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $84,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,472
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 6
Insurance contract or identification numberSOK602194
Number of Individuals Covered151
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 5
Insurance contract or identification numberSGM603446
Number of Individuals Covered151
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,699
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 numberGUC 0B32M
Policy instance 4
Insurance contract or identification numberGUC 0B32M
Number of Individuals Covered26
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $2,636
Total amount of fees paid to insurance companyUSD $224
Other welfare benefits providedVOLUNATRY SHORT TERM DISABILTY
Welfare Benefit Premiums Paid to CarrierUSD $17,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00356021
Policy instance 3
Insurance contract or identification number00356021
Number of Individuals Covered135
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $33,209
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $162,333
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 number920861
Policy instance 2
Insurance contract or identification number920861
Number of Individuals Covered211
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $8,167
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,752
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 numberGVTL0B32M
Policy instance 1
Insurance contract or identification numberGVTL0B32M
Number of Individuals Covered75
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $5,204
Total amount of fees paid to insurance companyUSD $404
Other welfare benefits providedLIFE AND A.D. & D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $34,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3331983
Policy instance 2
Insurance contract or identification number3331983
Number of Individuals Covered148
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $13,518
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $136,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,518
Insurance broker organization code?3
Insurance broker nameLEAVITT GROUP
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 3
Insurance contract or identification number356021
Number of Individuals Covered148
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $49,158
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $157,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,283
Insurance broker organization code?3
Insurance broker nameLEAVITT GROUP
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 4
Insurance contract or identification numberSOK602194
Number of Individuals Covered148
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $161
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTIAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13
Insurance broker organization code?3
Insurance broker nameLEAVITT INSURANCE SERVICE
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0281527
Policy instance 5
Insurance contract or identification numberR0281527
Number of Individuals Covered114
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $4,080
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D EE PAY
Welfare Benefit Premiums Paid to CarrierUSD $25,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10
Insurance broker organization code?3
Insurance broker nameLEAVITT INSURANCE SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 6
Insurance contract or identification numberSGM603446
Number of Individuals Covered148
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $997
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79
Insurance broker organization code?3
Insurance broker nameLEAVITT INSURANCE SERVICE
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008801524
Policy instance 1
Insurance contract or identification number0008801524
Number of Individuals Covered49
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $378
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, ISTDPROTEC
Welfare Benefit Premiums Paid to CarrierUSD $14,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $133
Insurance broker organization code?3
Insurance broker nameARROYO INSURANCE SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 6
Insurance contract or identification numberSGM603446
Number of Individuals Covered148
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $956
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $956
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 4
Insurance contract or identification numberSOK602194
Number of Individuals Covered148
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $159
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTIAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $159
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 3
Insurance contract or identification number356021
Number of Individuals Covered148
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $26,211
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $243,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,211
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3331983
Policy instance 2
Insurance contract or identification number3331983
Number of Individuals Covered147
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $12,315
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $124,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,315
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008801524
Policy instance 1
Insurance contract or identification number0008801524
Number of Individuals Covered51
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $390
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, ISTDPROTEC
Welfare Benefit Premiums Paid to CarrierUSD $16,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $145
Insurance broker organization code?3
Insurance broker nameARROYO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0281527
Policy instance 5
Insurance contract or identification numberR0281527
Number of Individuals Covered115
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $3,687
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D EE PAY
Welfare Benefit Premiums Paid to CarrierUSD $25,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,687
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3331983
Policy instance 1
Insurance contract or identification number3331983
Number of Individuals Covered145
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $11,179
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $112,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,179
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 2
Insurance contract or identification number356021
Number of Individuals Covered147
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $25,187
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $220,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,187
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 3
Insurance contract or identification numberSOK602194
Number of Individuals Covered147
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $138
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTIAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $138
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0281527
Policy instance 4
Insurance contract or identification numberR0281527
Number of Individuals Covered120
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $3,917
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D EE PAY
Welfare Benefit Premiums Paid to CarrierUSD $23,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,917
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 5
Insurance contract or identification numberSGM603446
Number of Individuals Covered145
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $827
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $827
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM603446
Policy instance 5
Insurance contract or identification numberSGM603446
Number of Individuals Covered134
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $827
Total amount of fees paid to insurance companyUSD $149
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $827
Amount paid for insurance broker fees149
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 2
Insurance contract or identification number356021
Number of Individuals Covered134
Insurance policy start date2013-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $24,717
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $185,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,717
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0281527
Policy instance 4
Insurance contract or identification numberR0281527
Number of Individuals Covered107
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $3,145
Total amount of fees paid to insurance companyUSD $223
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D EE PAY
Welfare Benefit Premiums Paid to CarrierUSD $20,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,145
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK602194
Policy instance 3
Insurance contract or identification numberSOK602194
Number of Individuals Covered134
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $138
Total amount of fees paid to insurance companyUSD $25
Other welfare benefits providedACCIDENTIAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $138
Amount paid for insurance broker fees25
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3331983
Policy instance 1
Insurance contract or identification number3331983
Number of Individuals Covered133
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $9,279
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $93,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,279
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0281527
Policy instance 3
Insurance contract or identification numberR0281527
Number of Individuals Covered115
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $2,832
Total amount of fees paid to insurance companyUSD $194
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D EE PAY
Welfare Benefit Premiums Paid to CarrierUSD $19,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3331983
Policy instance 1
Insurance contract or identification number3331983
Number of Individuals Covered128
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $8,718
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $87,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 2
Insurance contract or identification number356021
Number of Individuals Covered128
Insurance policy start date2012-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $24,678
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $179,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number356021
Policy instance 2
Insurance contract or identification number356021
Insurance policy start date2011-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $25,404
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $9,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3331983
Policy instance 1
Insurance contract or identification number3331983
Number of Individuals Covered131
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $8,340
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $84,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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