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FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 401k Plan overview

Plan NameFOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN
Plan identification number 501

FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN Benefits

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

401k Sponsoring company profile

FOX VALLEY METAL TECH, INC. has sponsored the creation of one or more 401k plans.

Company Name:FOX VALLEY METAL TECH, INC.
Employer identification number (EIN):391655192
NAIC Classification:332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-06-01
5012022-06-01
5012021-06-01
5012020-08-01
5012019-08-01
5012018-08-01
5012017-08-01JOHN WEST
5012016-08-01JOHN WEST

Plan Statistics for FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN

401k plan membership statisitcs for FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN

Measure Date Value
2023: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2023 401k membership
Total participants, beginning-of-year2023-06-01146
Total number of active participants reported on line 7a of the Form 55002023-06-01137
Number of retired or separated participants receiving benefits2023-06-010
Number of other retired or separated participants entitled to future benefits2023-06-010
Total of all active and inactive participants2023-06-01137
2022: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-01134
Total number of active participants reported on line 7a of the Form 55002022-06-01146
Number of retired or separated participants receiving benefits2022-06-010
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-01146
2021: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01108
Total number of active participants reported on line 7a of the Form 55002021-06-01111
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01111
2020: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01118
Total number of active participants reported on line 7a of the Form 55002020-08-01110
Number of retired or separated participants receiving benefits2020-08-010
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01110
2019: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01112
Total number of active participants reported on line 7a of the Form 55002019-08-01114
Number of retired or separated participants receiving benefits2019-08-010
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01114
2018: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01114
Total number of active participants reported on line 7a of the Form 55002018-08-01114
Number of retired or separated participants receiving benefits2018-08-010
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01114
2017: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01119
Total number of active participants reported on line 7a of the Form 55002017-08-01114
Number of retired or separated participants receiving benefits2017-08-010
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01114
2016: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01105
Total number of active participants reported on line 7a of the Form 55002016-08-01119
Number of retired or separated participants receiving benefits2016-08-010
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01119

Form 5500 Responses for FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN

2023: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2023 form 5500 responses
2023-06-01Type of plan entitySingle employer plan
2023-06-01Submission has been amendedNo
2023-06-01This submission is the final filingNo
2023-06-01This return/report is a short plan year return/report (less than 12 months)No
2023-06-01Plan is a collectively bargained planNo
2023-06-01Plan funding arrangement – InsuranceYes
2023-06-01Plan benefit arrangement – InsuranceYes
2022: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Submission has been amendedNo
2022-06-01This submission is the final filingNo
2022-06-01This return/report is a short plan year return/report (less than 12 months)No
2022-06-01Plan is a collectively bargained planNo
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – InsuranceYes
2021: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Submission has been amendedNo
2021-06-01This submission is the final filingNo
2021-06-01This return/report is a short plan year return/report (less than 12 months)No
2021-06-01Plan is a collectively bargained planNo
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – InsuranceYes
2020: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Submission has been amendedNo
2018-08-01This submission is the final filingNo
2018-08-01This return/report is a short plan year return/report (less than 12 months)No
2018-08-01Plan is a collectively bargained planNo
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – InsuranceYes
2016: FOX VALLEY METAL TECH, INC. LIFE AND DISABILITY INSURANCE PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01First time form 5500 has been submittedYes
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BKZT
Policy instance 4
Insurance contract or identification numberGVTL0BKZT
Number of Individuals Covered65
Insurance policy start date2023-06-01
Insurance policy end date2024-05-31
Total amount of commissions paid to insurance brokerUSD $4,868
Total amount of fees paid to insurance companyUSD $1,487
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 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 CarrierUSD $33,385
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 numberGUPR0BKZT
Policy instance 3
Insurance contract or identification numberGUPR0BKZT
Number of Individuals Covered86
Insurance policy start date2023-06-01
Insurance policy end date2024-05-31
Total amount of commissions paid to insurance brokerUSD $2,739
Total amount of fees paid to insurance companyUSD $898
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 $19,886
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 numberGUG 0BKZT
Policy instance 2
Insurance contract or identification numberGUG 0BKZT
Number of Individuals Covered111
Insurance policy start date2023-06-01
Insurance policy end date2024-05-31
Total amount of commissions paid to insurance brokerUSD $3,394
Total amount of fees paid to insurance companyUSD $1,665
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,426
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 numberGLUG0BKZT
Policy instance 1
Insurance contract or identification numberGLUG0BKZT
Number of Individuals Covered135
Insurance policy start date2023-06-01
Insurance policy end date2024-05-31
Total amount of commissions paid to insurance brokerUSD $478
Total amount of fees paid to insurance companyUSD $232
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 $4,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BKZT
Policy instance 4
Insurance contract or identification numberGVTL0BKZT
Number of Individuals Covered70
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $4,757
Total amount of fees paid to insurance companyUSD $863
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 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 CarrierUSD $31,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,757
Amount paid for insurance broker fees863
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0BKZT
Policy instance 3
Insurance contract or identification numberGUPR0BKZT
Number of Individuals Covered81
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,662
Total amount of fees paid to insurance companyUSD $509
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 $18,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,662
Amount paid for insurance broker fees509
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0BKZT
Policy instance 2
Insurance contract or identification numberGUG 0BKZT
Number of Individuals Covered107
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $3,277
Total amount of fees paid to insurance companyUSD $1,058
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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,277
Amount paid for insurance broker fees1058
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BKZT
Policy instance 1
Insurance contract or identification numberGLUG0BKZT
Number of Individuals Covered139
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $523
Total amount of fees paid to insurance companyUSD $133
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 $5,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $523
Amount paid for insurance broker fees133
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BKZT
Policy instance 1
Insurance contract or identification numberG000BKZT
Number of Individuals Covered112
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $10,332
Total amount of fees paid to insurance companyUSD $1,722
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 BenefitYes
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 $84,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,332
Amount paid for insurance broker fees1722
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BKZT
Policy instance 1
Insurance contract or identification numberG000BKZT
Number of Individuals Covered110
Insurance policy start date2020-08-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $9,138
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 BenefitYes
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 $71,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,138
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BKZT
Policy instance 1
Insurance contract or identification numberG000BKZT
Number of Individuals Covered114
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $10,440
Total amount of fees paid to insurance companyUSD $327
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 BenefitYes
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 $86,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,440
Amount paid for insurance broker fees327
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )
Policy contract number23625
Policy instance 1
Insurance contract or identification number23625
Number of Individuals Covered112
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $7,024
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 BenefitYes
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 $61,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,024
Insurance broker organization code?3
KANSAS CITY LIFE (National Association of Insurance Commissioners NAIC id number: 65129 )
Policy contract number23625
Policy instance 1
Insurance contract or identification number23625
Number of Individuals Covered114
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $6,894
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 BenefitYes
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 $61,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,894
Insurance broker organization code?3
Insurance broker nameSHARON SIMON

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