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WELFARE BENEFIT PLAN VISION 401k Plan overview

Plan NameWELFARE BENEFIT PLAN VISION
Plan identification number 504

WELFARE BENEFIT PLAN VISION Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Vision

401k Sponsoring company profile

POLLY INSURANCE AGENCY, LLC has sponsored the creation of one or more 401k plans.

Company Name:POLLY INSURANCE AGENCY, LLC
Employer identification number (EIN):810948786
NAIC Classification:524210
NAIC Description:Insurance Agencies and Brokerages

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WELFARE BENEFIT PLAN VISION

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042022-10-01

Plan Statistics for WELFARE BENEFIT PLAN VISION

401k plan membership statisitcs for WELFARE BENEFIT PLAN VISION

Measure Date Value
2022: WELFARE BENEFIT PLAN VISION 2022 401k membership
Total participants, beginning-of-year2022-10-01190
Total number of active participants reported on line 7a of the Form 55002022-10-010
Number of retired or separated participants receiving benefits2022-10-010
Number of other retired or separated participants entitled to future benefits2022-10-010
Total of all active and inactive participants2022-10-010

Form 5500 Responses for WELFARE BENEFIT PLAN VISION

2022: WELFARE BENEFIT PLAN VISION 2022 form 5500 responses
2022-10-01Type of plan entitySingle employer plan
2022-10-01First time form 5500 has been submittedYes
2022-10-01Submission has been amendedNo
2022-10-01This submission is the final filingYes
2022-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-10-01Plan is a collectively bargained planNo
2022-10-01Plan funding arrangement – InsuranceYes
2022-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30093971
Policy instance 1
Insurance contract or identification number30093971
Number of Individuals Covered191
Insurance policy start date2022-10-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $214
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $214
Insurance broker organization code?3

Potentially related plans

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