CITY OF WEISER has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CITY OF WEISER EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2015: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-11-01 | 56 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-11-01 | 59 |
| Number of retired or separated participants receiving benefits | 2015-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-11-01 | 0 |
| Total of all active and inactive participants | 2015-11-01 | 59 |
| 2014: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-11-01 | 63 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 56 |
| Number of retired or separated participants receiving benefits | 2014-11-01 | 0 |
| Total of all active and inactive participants | 2014-11-01 | 56 |
| 2013: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 60 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 62 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 1 |
| Total of all active and inactive participants | 2013-11-01 | 63 |
| 2012: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 61 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 59 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 1 |
| Total of all active and inactive participants | 2012-11-01 | 60 |
| 2011: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 63 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 61 |
| Total of all active and inactive participants | 2011-11-01 | 61 |
| Total participants | 2011-11-01 | 61 |
| 2010: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-11-01 | 62 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-11-01 | 63 |
| Number of retired or separated participants receiving benefits | 2010-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-11-01 | 0 |
| Total of all active and inactive participants | 2010-11-01 | 63 |
| Total participants | 2010-11-01 | 63 |
| 2009: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 61 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 62 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 0 |
| Total of all active and inactive participants | 2009-11-01 | 62 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-11-01 | 0 |
| Total participants | 2009-11-01 | 62 |
| Measure | Date | Value |
|---|
| 2016 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2016 401k financial data |
|---|
| Total plan liabilities at end of year | 2016-10-31 | $0 |
| Total plan liabilities at beginning of year | 2016-10-31 | $0 |
| Total income from all sources | 2016-10-31 | $857,384 |
| Expenses. Total of all expenses incurred | 2016-10-31 | $857,384 |
| Benefits paid (including direct rollovers) | 2016-10-31 | $811,293 |
| Total plan assets at end of year | 2016-10-31 | $0 |
| Total plan assets at beginning of year | 2016-10-31 | $0 |
| Value of fidelity bond covering the plan | 2016-10-31 | $500,000 |
| Total contributions received or receivable from participants | 2016-10-31 | $181,082 |
| Net income (gross income less expenses) | 2016-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2016-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2016-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2016-10-31 | $676,302 |
| Value of corrective distributions | 2016-10-31 | $46,091 |
| 2015 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2015 401k financial data |
|---|
| Total plan liabilities at end of year | 2015-10-31 | $0 |
| Total plan liabilities at beginning of year | 2015-10-31 | $0 |
| Total income from all sources | 2015-10-31 | $838,165 |
| Expenses. Total of all expenses incurred | 2015-10-31 | $838,165 |
| Benefits paid (including direct rollovers) | 2015-10-31 | $790,894 |
| Total plan assets at end of year | 2015-10-31 | $0 |
| Total plan assets at beginning of year | 2015-10-31 | $0 |
| Value of fidelity bond covering the plan | 2015-10-31 | $500,000 |
| Total contributions received or receivable from participants | 2015-10-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2015-10-31 | $178,926 |
| Net income (gross income less expenses) | 2015-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2015-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2015-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2015-10-31 | $659,239 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2015-10-31 | $47,271 |
| 2014 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2014 401k financial data |
|---|
| Transfers to/from the plan | 2014-10-31 | $0 |
| Total plan liabilities at end of year | 2014-10-31 | $0 |
| Total plan liabilities at beginning of year | 2014-10-31 | $0 |
| Total income from all sources | 2014-10-31 | $1,013,429 |
| Expenses. Total of all expenses incurred | 2014-10-31 | $1,013,429 |
| Benefits paid (including direct rollovers) | 2014-10-31 | $965,238 |
| Total plan assets at end of year | 2014-10-31 | $0 |
| Total plan assets at beginning of year | 2014-10-31 | $0 |
| Total contributions received or receivable from participants | 2014-10-31 | $0 |
| Expenses. Other expenses not covered elsewhere | 2014-10-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2014-10-31 | $156,030 |
| Other income received | 2014-10-31 | $0 |
| Noncash contributions received | 2014-10-31 | $0 |
| Net income (gross income less expenses) | 2014-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2014-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2014-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2014-10-31 | $857,399 |
| Value of certain deemed distributions of participant loans | 2014-10-31 | $0 |
| Value of corrective distributions | 2014-10-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2014-10-31 | $48,191 |
| 2013 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2013 401k financial data |
|---|
| Total plan liabilities at end of year | 2013-10-31 | $0 |
| Total plan liabilities at beginning of year | 2013-10-31 | $0 |
| Total income from all sources | 2013-10-31 | $573,737 |
| Expenses. Total of all expenses incurred | 2013-10-31 | $573,737 |
| Benefits paid (including direct rollovers) | 2013-10-31 | $530,053 |
| Total plan assets at end of year | 2013-10-31 | $0 |
| Total plan assets at beginning of year | 2013-10-31 | $0 |
| Total contributions received or receivable from participants | 2013-10-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2013-10-31 | $10,823 |
| Other income received | 2013-10-31 | $0 |
| Noncash contributions received | 2013-10-31 | $0 |
| Net income (gross income less expenses) | 2013-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2013-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2013-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2013-10-31 | $562,914 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2013-10-31 | $43,684 |
| 2012 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2012 401k financial data |
|---|
| Total plan liabilities at end of year | 2012-10-31 | $0 |
| Total plan liabilities at beginning of year | 2012-10-31 | $0 |
| Total income from all sources | 2012-10-31 | $911,069 |
| Expenses. Total of all expenses incurred | 2012-10-31 | $911,069 |
| Benefits paid (including direct rollovers) | 2012-10-31 | $866,094 |
| Total plan assets at end of year | 2012-10-31 | $0 |
| Total plan assets at beginning of year | 2012-10-31 | $0 |
| Total contributions received or receivable from participants | 2012-10-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2012-10-31 | $203,835 |
| Other income received | 2012-10-31 | $0 |
| Noncash contributions received | 2012-10-31 | $0 |
| Net income (gross income less expenses) | 2012-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2012-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2012-10-31 | $707,234 |
| Value of certain deemed distributions of participant loans | 2012-10-31 | $0 |
| Value of corrective distributions | 2012-10-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-10-31 | $44,975 |
| 2011 : CITY OF WEISER EMPLOYEE BENEFIT PLAN 2011 401k financial data |
|---|
| Total plan liabilities at end of year | 2011-10-31 | $0 |
| Total plan liabilities at beginning of year | 2011-10-31 | $0 |
| Total income from all sources | 2011-10-31 | $560,160 |
| Expenses. Total of all expenses incurred | 2011-10-31 | $560,160 |
| Benefits paid (including direct rollovers) | 2011-10-31 | $541,540 |
| Total plan assets at end of year | 2011-10-31 | $0 |
| Total plan assets at beginning of year | 2011-10-31 | $0 |
| Total contributions received or receivable from participants | 2011-10-31 | $0 |
| Expenses. Other expenses not covered elsewhere | 2011-10-31 | $0 |
| Contributions received from other sources (not participants or employers) | 2011-10-31 | $54,486 |
| Other income received | 2011-10-31 | $0 |
| Noncash contributions received | 2011-10-31 | $0 |
| Net income (gross income less expenses) | 2011-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2011-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2011-10-31 | $505,674 |
| Value of certain deemed distributions of participant loans | 2011-10-31 | $0 |
| Value of corrective distributions | 2011-10-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2011-10-31 | $18,620 |
| 2015: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-11-01 | Type of plan entity | Single employer plan |
| 2015-11-01 | Submission has been amended | No |
| 2015-11-01 | This submission is the final filing | No |
| 2015-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-11-01 | Plan is a collectively bargained plan | No |
| 2015-11-01 | Plan funding arrangement – Insurance | Yes |
| 2015-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-11-01 | Type of plan entity | Single employer plan |
| 2014-11-01 | Submission has been amended | No |
| 2014-11-01 | This submission is the final filing | No |
| 2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-11-01 | Plan is a collectively bargained plan | No |
| 2014-11-01 | Plan funding arrangement – Insurance | Yes |
| 2014-11-01 | Plan funding arrangement – Trust | Yes |
| 2014-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-11-01 | Plan benefit arrangement - Trust | Yes |
| 2014-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Submission has been amended | No |
| 2013-11-01 | This submission is the final filing | No |
| 2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-11-01 | Plan is a collectively bargained plan | No |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-11-01 | Type of plan entity | Single employer plan |
| 2010-11-01 | Submission has been amended | No |
| 2010-11-01 | This submission is the final filing | No |
| 2010-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-11-01 | Plan is a collectively bargained plan | No |
| 2010-11-01 | Plan funding arrangement – Insurance | Yes |
| 2010-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: CITY OF WEISER EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | No |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS00506-15 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS00506-15 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of commissions paid to insurance broker | USD $3,327 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $166,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,327 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MST INSURANCE AGENCY |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS00506-14 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS00506-14 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $3,547 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $177,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,547 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MST INSURANCE AGENCY |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS0050613 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS0050613 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $3,779 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $188,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,779 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MST INSURANCE AGENCY |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS0050612 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS0050612 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | 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? | No | | 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 | Yes | | 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 $169,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS0050611 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS0050611 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | 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? | No | | 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 | Yes | | 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 $158,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| QBE INSURANCE (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS0050610 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS0050610 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $27,498 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | Yes | | 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 $183,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
