FLEETWOOD METAL INDUSTRIES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN
401k plan membership statisitcs for CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 108 |
| Total of all active and inactive participants | 2022-02-01 | 108 |
| 2021: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 373 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 356 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 2 |
| Total of all active and inactive participants | 2021-02-01 | 358 |
| 2020: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 433 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 330 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 0 |
| Total of all active and inactive participants | 2020-02-01 | 330 |
| 2019: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 182 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 182 |
| 2018: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 239 |
| Total of all active and inactive participants | 2018-02-01 | 239 |
| 2017: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 204 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 204 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-02-01 | 0 |
| Total participants, beginning-of-year | 2017-01-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 204 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 204 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-01-01 | 0 |
| Total participants | 2017-01-01 | 204 |
| 2016: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 185 |
| Total of all active and inactive participants | 2016-02-01 | 185 |
| Total participants | 2016-02-01 | 185 |
| 2015: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 138 |
| Total of all active and inactive participants | 2015-02-01 | 138 |
| 2014: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 182 |
| Total of all active and inactive participants | 2014-02-01 | 182 |
| Total participants | 2014-02-01 | 182 |
| 2022: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | Yes |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Submission has been amended | Yes |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | Yes |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | First time form 5500 has been submitted | Yes |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CLEVELAND-CLIFFS TOOLING AND STAMPING - FLEETWOOD WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 0073785 |
| Policy instance | 6 |
| Insurance contract or identification number | 0073785 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | BABY YOURSELF, AIR MEDICAL | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $1,129 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,129 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 4 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $6,093 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,933 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,093 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AAUS |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AAUS | | Number of Individuals Covered | 76 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-07-01 | | Total amount of commissions paid to insurance broker | USD $5,714 | | Total amount of fees paid to insurance company | USD $2,339 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $38,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,714 | | Amount paid for insurance broker fees | 1936 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0AAUS |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0AAUS | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-07-01 | | Total amount of commissions paid to insurance broker | USD $6,201 | | Total amount of fees paid to insurance company | USD $1,870 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $41,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,201 | | Amount paid for insurance broker fees | 1548 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AAUS | | Number of Individuals Covered | 123 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-07-01 | | Total amount of commissions paid to insurance broker | USD $4,701 | | Total amount of fees paid to insurance company | USD $2,188 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $31,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,701 | | Amount paid for insurance broker fees | 1811 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 2 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 65 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $3,220 | | Total amount of fees paid to insurance company | USD $2,060 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $21,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,220 | | Amount paid for insurance broker fees | 1436 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 58 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $3,880 | | Total amount of fees paid to insurance company | USD $2,185 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $25,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,880 | | Amount paid for insurance broker fees | 1553 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 4 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $6,528 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,528 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $1,183 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,183 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 0073785 |
| Policy instance | 6 |
| Insurance contract or identification number | 0073785 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | BABY YOURSELF, AIR MEDICAL, EXP PSY | | 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 | G000AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 113 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $4,749 | | Total amount of fees paid to insurance company | USD $3,165 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $31,658 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,749 | | Amount paid for insurance broker fees | 2193 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 150 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $6,040 | | Total amount of fees paid to insurance company | USD $2,472 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,264 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,040 | | Amount paid for insurance broker fees | 2472 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 51 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $3,601 | | Total amount of fees paid to insurance company | USD $1,480 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $24,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,601 | | Amount paid for insurance broker fees | 1480 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 4 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $7,718 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,718 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,298 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,298 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 0073785 |
| Policy instance | 6 |
| Insurance contract or identification number | 0073785 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | BABY YOURSELF & AIR MEDICAL SERVICE | | 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 | G000AAUS |
| Policy instance | 2 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 61 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $4,062 | | Total amount of fees paid to insurance company | USD $1,557 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $27,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,062 | | Amount paid for insurance broker fees | 1557 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,681 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,681 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 4 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $10,796 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $107,959 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,796 | | 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 | GUG OAAUS |
| Policy instance | 3 |
| Insurance contract or identification number | GUG OAAUS | | Number of Individuals Covered | 87 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $3,345 | | Total amount of fees paid to insurance company | USD $920 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SHORT TERM DISABILITY INSURED | | 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 $22,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,345 | | Amount paid for insurance broker fees | 920 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOAAUS |
| Policy instance | 1 |
| Insurance contract or identification number | GLUGOAAUS | | Number of Individuals Covered | 194 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $6,577 | | Total amount of fees paid to insurance company | USD $1,944 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,577 | | Amount paid for insurance broker fees | 1944 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOAAUS |
| Policy instance | 2 |
| Insurance contract or identification number | GVTLOAAUS | | Number of Individuals Covered | 67 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $4,202 | | Total amount of fees paid to insurance company | USD $1,365 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D VOLUNTARY | | 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 $28,013 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,202 | | Amount paid for insurance broker fees | 1365 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 6 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,184 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,184 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 5 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $9,350 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $100,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,350 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10121141001 |
| Policy instance | 4 |
| Insurance contract or identification number | 10121141001 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $525 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,054 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $525 | | 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 | G0000AAUS |
| Policy instance | 3 |
| Insurance contract or identification number | G0000AAUS | | Number of Individuals Covered | 103 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $2,544 | | Total amount of fees paid to insurance company | USD $759 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,544 | | Amount paid for insurance broker fees | 759 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G0000AAUS |
| Policy instance | 2 |
| Insurance contract or identification number | G0000AAUS | | Number of Individuals Covered | 94 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $4,483 | | Total amount of fees paid to insurance company | USD $1,310 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT - VOLUNTARY | | 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 $29,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,195 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 247 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $5,326 | | Total amount of fees paid to insurance company | USD $1,369 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,502 | | Amount paid for insurance broker fees | 1369 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 2 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 85 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-07-01 | | Total amount of commissions paid to insurance broker | USD $4,410 | | Total amount of fees paid to insurance company | USD $978 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH 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 $29,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,410 | | Amount paid for insurance broker fees | 978 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | S S NESBITT & CO INC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 18467 |
| Policy instance | 3 |
| Insurance contract or identification number | 18467 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2016-09-01 | | Insurance policy end date | 2017-08-31 | | Total amount of commissions paid to insurance broker | USD $7,847 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $78,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,896 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | VAN METER INS AGENCY INC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 0073785 |
| Policy instance | 4 |
| Insurance contract or identification number | 0073785 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2017-03-31 | | 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? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EXPANDED PSYCHIATRIC SERVICES (EPS) BABY YOURSELF/AIR MEDICAL SERVICES (AIRMED) | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,352 | | 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 | G000AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 190 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-07-01 | | Total amount of commissions paid to insurance broker | USD $5,705 | | Total amount of fees paid to insurance company | USD $1,159 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH 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 $38,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,705 | | Amount paid for insurance broker fees | 1159 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | S S NESBITT & CO INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 1 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 190 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-07-01 | | Total amount of commissions paid to insurance broker | USD $5,705 | | Total amount of fees paid to insurance company | USD $1,159 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH 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 $38,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,705 | | Amount paid for insurance broker fees | 1159 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | SS NESBITT & CO INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05916816 |
| Policy instance | 5 |
| Insurance contract or identification number | KM05916816 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $890 | | Total amount of fees paid to insurance company | USD $374 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $890 | | Amount paid for insurance broker fees | 374 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05916816 |
| Policy instance | 4 |
| Insurance contract or identification number | KM05916816 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $162 | | Total amount of fees paid to insurance company | USD $31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $162 | | Amount paid for insurance broker fees | 31 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AAUS |
| Policy instance | 3 |
| Insurance contract or identification number | G000AAUS | | Number of Individuals Covered | 152 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $3,274 | | Total amount of fees paid to insurance company | USD $1,023 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,274 | | Amount paid for insurance broker fees | 1023 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | S S NESBITT & CO INC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 15615 |
| Policy instance | 2 |
| Insurance contract or identification number | 15615 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EPS, BABY YOURSELF, AND AIRMED | | Welfare Benefit Premiums Paid to Carrier | USD $12,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 54097 ) |
| Policy contract number | 2401-003 |
| Policy instance | 1 |
| Insurance contract or identification number | 2401-003 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $1,069 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,759 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,069 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP |
|
