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GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 401k Plan overview

Plan NameGROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN
Plan identification number 503

GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

BELMARK INC has sponsored the creation of one or more 401k plans.

Company Name:BELMARK INC
Employer identification number (EIN):391283237
NAIC Classification:323100

Additional information about BELMARK INC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5506771

More information about BELMARK INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032023-01-01
5032022-01-01
5032021-01-01
5032020-01-01
5032019-01-01
5032018-01-01
5032017-01-01
5032016-01-01
5032015-01-01
5032014-01-01
5032013-01-01
5032012-01-01KARL SCHMIDT
5032011-01-01KARL SCHMIDT
5032009-01-01KARL SCHMIDT

Plan Statistics for GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN

401k plan membership statisitcs for GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN

Measure Date Value
2023: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2023 401k membership
Total participants, beginning-of-year2023-01-011,185
Total number of active participants reported on line 7a of the Form 55002023-01-010
Number of retired or separated participants receiving benefits2023-01-010
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-010
2022: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-011,028
Total number of active participants reported on line 7a of the Form 55002022-01-011,165
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-011,165
2021: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01971
Total number of active participants reported on line 7a of the Form 55002021-01-011,028
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-011,028
2020: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01857
Total number of active participants reported on line 7a of the Form 55002020-01-01944
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01944
2019: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01824
Total number of active participants reported on line 7a of the Form 55002019-01-01857
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01857
2018: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01746
Total number of active participants reported on line 7a of the Form 55002018-01-01820
Total of all active and inactive participants2018-01-01820
2017: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01725
Total number of active participants reported on line 7a of the Form 55002017-01-01746
Total of all active and inactive participants2017-01-01746
2016: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01688
Total number of active participants reported on line 7a of the Form 55002016-01-01725
Total of all active and inactive participants2016-01-01725
2015: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01625
Total number of active participants reported on line 7a of the Form 55002015-01-01688
Total of all active and inactive participants2015-01-01688
2014: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01581
Total number of active participants reported on line 7a of the Form 55002014-01-01625
Total of all active and inactive participants2014-01-01625
2013: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01530
Total number of active participants reported on line 7a of the Form 55002013-01-01581
Total of all active and inactive participants2013-01-01581
2012: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01500
Total number of active participants reported on line 7a of the Form 55002012-01-01530
Total of all active and inactive participants2012-01-01530
2011: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01482
Total number of active participants reported on line 7a of the Form 55002011-01-01500
Total of all active and inactive participants2011-01-01500
2009: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01428
Total number of active participants reported on line 7a of the Form 55002009-01-01437
Total of all active and inactive participants2009-01-01437

Form 5500 Responses for GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN

2023: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Submission has been amendedNo
2023-01-01This submission is the final filingYes
2023-01-01This return/report is a short plan year return/report (less than 12 months)No
2023-01-01Plan is a collectively bargained planNo
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – InsuranceYes
2022: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: GROUP TERM LIFE, ACCIDENTAL DEATH & DISMEMBERMENT, AND LONG TERM DISABILITY PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0245456
Policy instance 1
Insurance contract or identification number0245456
Number of Individuals Covered1221
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $19,026
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $260,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255600
Policy instance 2
Insurance contract or identification number10255600
Number of Individuals Covered1165
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,318
Total amount of fees paid to insurance companyUSD $698
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 BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $163,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,022
Amount paid for insurance broker fees698
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255602
Policy instance 1
Insurance contract or identification number10255602
Number of Individuals Covered1166
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,802
Total amount of fees paid to insurance companyUSD $209
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $44,587
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,469
Amount paid for insurance broker fees209
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255600
Policy instance 2
Insurance contract or identification number10255600
Number of Individuals Covered1023
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,198
Total amount of fees paid to insurance companyUSD $1,221
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 BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $139,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,198
Amount paid for insurance broker fees1221
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255602
Policy instance 1
Insurance contract or identification number10255602
Number of Individuals Covered1023
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,744
Total amount of fees paid to insurance companyUSD $372
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $41,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,744
Amount paid for insurance broker fees372
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255600
Policy instance 2
Insurance contract or identification number10255600
Number of Individuals Covered944
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,111
Total amount of fees paid to insurance companyUSD $4,890
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 BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $122,147
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,111
Insurance broker organization code?3
Amount paid for insurance broker fees4890
Additional information about fees paid to insurance brokerBROKER BONUS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 )
Policy contract number10255602
Policy instance 1
Insurance contract or identification number10255602
Number of Individuals Covered944
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,654
Total amount of fees paid to insurance companyUSD $1,769
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $37,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,654
Insurance broker organization code?3
Amount paid for insurance broker fees1769
Additional information about fees paid to insurance brokerBROKER BONUS
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number0101711400
Policy instance 1
Insurance contract or identification number0101711400
Number of Individuals Covered857
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $9,654
Total amount of fees paid to insurance companyUSD $8,215
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $150,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,851
Amount paid for insurance broker fees8215
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number0101711400
Policy instance 1
Insurance contract or identification number0101711400
Number of Individuals Covered820
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $9,422
Total amount of fees paid to insurance companyUSD $5,007
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $140,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,422
Insurance broker organization code?3
Amount paid for insurance broker fees5007
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number0101711400
Policy instance 2
Insurance contract or identification number0101711400
Number of Individuals Covered746
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $5,702
Total amount of fees paid to insurance companyUSD $3,021
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $119,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,702
Insurance broker organization code?3
Amount paid for insurance broker fees3021
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker nameTHE HAYS GROUP INC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number871981G
Policy instance 1
Insurance contract or identification number871981G
Number of Individuals Covered725
Insurance policy start date2017-01-01
Insurance policy end date2017-01-01
Total amount of commissions paid to insurance brokerUSD $191
Total amount of fees paid to insurance companyUSD $2,408
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $12,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2408
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $191
Insurance broker nameHAYS GROUP OF WI LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number871981G
Policy instance 1
Insurance contract or identification number871981G
Number of Individuals Covered688
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,321
Total amount of fees paid to insurance companyUSD $1,383
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $126,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,321
Insurance broker organization code?3
Amount paid for insurance broker fees1383
Additional information about fees paid to insurance brokerBONUS PAID.
Insurance broker nameHAYS GROUP OF WI LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number871981G
Policy instance 1
Insurance contract or identification number871981G
Number of Individuals Covered625
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $8,735
Total amount of fees paid to insurance companyUSD $1,909
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $92,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,735
Insurance broker organization code?3
Amount paid for insurance broker fees1909
Additional information about fees paid to insurance brokerBONUS PAID.
Insurance broker nameHAYS GROUP OF WI LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number871981G
Policy instance 1
Insurance contract or identification number871981G
Number of Individuals Covered581
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $8,464
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $91,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,464
Insurance broker organization code?3
Insurance broker nameHAYS GROUP OF WI LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number871981G
Policy instance 1
Insurance contract or identification number871981G
Number of Individuals Covered530
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $8,280
Total amount of fees paid to insurance companyUSD $2,894
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $73,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,280
Insurance broker organization code?3
Amount paid for insurance broker fees2894
Additional information about fees paid to insurance brokerBONUS
Insurance broker nameHAYS BENEFITS GROUP LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0069674
Policy instance 1
Insurance contract or identification numberR0069674
Number of Individuals Covered500
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $6,405
Total amount of fees paid to insurance companyUSD $38
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $74,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract numberR0069674
Policy instance 1
Insurance contract or identification numberR0069674
Number of Individuals Covered482
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $6,401
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $70,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,401
Insurance broker organization code?3
Insurance broker nameTHE HAYS BENEFITS GROUP OF WISCONSI

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