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SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameSUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN
Plan identification number 502

SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SUPER ENTERPRISES-USA, INC. has sponsored the creation of one or more 401k plans.

Company Name:SUPER ENTERPRISES-USA, INC.
Employer identification number (EIN):113471521
NAIC Classification:423300

Additional information about SUPER ENTERPRISES-USA, INC.

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1998-04-30
Company Identification Number: 2254857
Legal Registered Office Address: 126 SPAGNOLI ROAD
Suffolk
MELVILLE
United States of America (USA)
11747

More information about SUPER ENTERPRISES-USA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022020-05-01
5022019-05-01
5022018-05-01
5022017-05-01PETER BORZILLERI
5022016-05-01PETER BORZILLERI
5022015-05-01PETER BORZILLERI
5022014-05-01PETER BORZILLERI
5022013-05-01RICHARD BELENSKI, CHIEF OPER OFCR
5022012-05-01KATHY DONLON
5022011-05-01KATHY DONLON
5022010-05-01KATHY DONLON
5022009-05-01KATHY DONLON
5022009-05-01KATHY DONLON
5022009-05-01KATHY DONLON
5022009-05-01KATHY DONLON
5022009-05-01KATHY DONLON

Plan Statistics for SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2020: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01137
Total number of active participants reported on line 7a of the Form 55002020-05-0165
Total of all active and inactive participants2020-05-0165
Total participants2020-05-0165
2019: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01141
Total number of active participants reported on line 7a of the Form 55002019-05-01137
Total of all active and inactive participants2019-05-01137
Total participants2019-05-01137
2018: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01145
Total number of active participants reported on line 7a of the Form 55002018-05-01141
Total of all active and inactive participants2018-05-01141
Total participants2018-05-01141
2017: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01108
Total number of active participants reported on line 7a of the Form 55002017-05-01145
Total of all active and inactive participants2017-05-01145
Total participants2017-05-01145
2016: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01110
Total number of active participants reported on line 7a of the Form 55002016-05-01108
Total of all active and inactive participants2016-05-01108
Total participants2016-05-01108
2015: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01107
Total number of active participants reported on line 7a of the Form 55002015-05-01110
Total of all active and inactive participants2015-05-01110
Total participants2015-05-010
2014: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01109
Total number of active participants reported on line 7a of the Form 55002014-05-01107
Total of all active and inactive participants2014-05-01107
Total participants2014-05-010
2013: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01104
Total number of active participants reported on line 7a of the Form 55002013-05-01109
Total of all active and inactive participants2013-05-01109
Total participants2013-05-010
2012: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01107
Total number of active participants reported on line 7a of the Form 55002012-05-01104
Total of all active and inactive participants2012-05-01104
Total participants2012-05-010
2011: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01104
Total number of active participants reported on line 7a of the Form 55002011-05-01107
Total of all active and inactive participants2011-05-01107
Total participants2011-05-01107
2010: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01108
Total number of active participants reported on line 7a of the Form 55002010-05-0197
Number of retired or separated participants receiving benefits2010-05-017
Number of other retired or separated participants entitled to future benefits2010-05-010
Total of all active and inactive participants2010-05-01104
2009: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-01119
Total number of active participants reported on line 7a of the Form 55002009-05-01101
Number of retired or separated participants receiving benefits2009-05-017
Number of other retired or separated participants entitled to future benefits2009-05-010
Total of all active and inactive participants2009-05-01108

Financial Data on SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2021 : SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2021 401k financial data
Value of total assets at end of year2021-04-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-04-30No
Was this plan covered by a fidelity bond2021-04-30No
If this is an individual account plan, was there a blackout period2021-04-30No
Were there any nonexempt tranactions with any party-in-interest2021-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2021-04-30No
Were any leases to which the plan was party in default or uncollectible2021-04-30No
Value of interest in pooled separate accounts at end of year2021-04-30$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-04-30No
Was there a failure to transmit to the plan any participant contributions2021-04-30No
Has the plan failed to provide any benefit when due under the plan2021-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32021-04-30No
Did the plan have assets held for investment2021-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-04-30No
2020 : SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2020 401k financial data
Value of total assets at end of year2020-04-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-04-30No
Was this plan covered by a fidelity bond2020-04-30No
If this is an individual account plan, was there a blackout period2020-04-30No
Were there any nonexempt tranactions with any party-in-interest2020-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2020-04-30No
Were any leases to which the plan was party in default or uncollectible2020-04-30No
Value of interest in pooled separate accounts at end of year2020-04-30$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-04-30No
Was there a failure to transmit to the plan any participant contributions2020-04-30No
Has the plan failed to provide any benefit when due under the plan2020-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32020-04-30No
Did the plan have assets held for investment2020-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-04-30No
2019 : SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2019 401k financial data
Value of total assets at end of year2019-04-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-04-30No
Was this plan covered by a fidelity bond2019-04-30No
If this is an individual account plan, was there a blackout period2019-04-30No
Were there any nonexempt tranactions with any party-in-interest2019-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2019-04-30No
Were any leases to which the plan was party in default or uncollectible2019-04-30No
Value of interest in pooled separate accounts at end of year2019-04-30$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-04-30No
Was there a failure to transmit to the plan any participant contributions2019-04-30No
Has the plan failed to provide any benefit when due under the plan2019-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-04-30No
Did the plan have assets held for investment2019-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-04-30No

Form 5500 Responses for SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN

2020: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – InsuranceYes
2019: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – InsuranceYes
2018: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – InsuranceYes
2017: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – InsuranceYes
2016: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – InsuranceYes
2015: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – InsuranceYes
2014: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – InsuranceYes
2013: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – InsuranceYes
2012: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Submission has been amendedNo
2010-05-01This submission is the final filingNo
2010-05-01This return/report is a short plan year return/report (less than 12 months)No
2010-05-01Plan is a collectively bargained planNo
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – InsuranceYes
2009: SUPER ENTERPRISES-USA, INC. HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01Submission has been amendedYes
2009-05-01This submission is the final filingNo
2009-05-01This return/report is a short plan year return/report (less than 12 months)No
2009-05-01Plan is a collectively bargained planNo
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGE600426
Policy instance 6
Insurance contract or identification numberSGE600426
Number of Individuals Covered64
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $3,238
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,238
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYK700161
Policy instance 5
Insurance contract or identification numberNYK700161
Number of Individuals Covered64
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $2,454
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $30,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,454
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered112
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $44,124
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $763,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,124
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered37
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,577
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,577
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered65
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,944
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,393
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Insurance policy start date2020-02-01
Insurance policy end date2021-02-01
Total amount of fees paid to insurance companyUSD $37
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees37
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Insurance policy start date2019-02-01
Insurance policy end date2020-02-01
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYK700161
Policy instance 5
Insurance contract or identification numberNYK700161
Number of Individuals Covered137
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $2,701
Total amount of fees paid to insurance companyUSD $1,751
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,701
Amount paid for insurance broker fees1751
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered211
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of fees paid to insurance companyUSD $49,470
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $830,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees49470
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered75
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $1,725
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,725
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGE600426
Policy instance 6
Insurance contract or identification numberSGE600426
Number of Individuals Covered137
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $3,597
Total amount of fees paid to insurance companyUSD $1,597
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $31,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,597
Amount paid for insurance broker fees1597
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered38
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $2,935
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $16,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,054
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered131
Insurance policy start date2018-02-01
Insurance policy end date2019-02-01
Total amount of commissions paid to insurance brokerUSD $561
Total amount of fees paid to insurance companyUSD $196
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $3,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $561
Insurance broker organization code?3
Amount paid for insurance broker fees187
Additional information about fees paid to insurance brokerSALES AND SERVICE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered131
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $861
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $17,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $861
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered72
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $1,713
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,713
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered212
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of fees paid to insurance companyUSD $43,765
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $757,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees43765
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYK700161
Policy instance 5
Insurance contract or identification numberNYK700161
Number of Individuals Covered141
Insurance policy start date2018-05-01
Insurance policy end date2019-05-01
Total amount of commissions paid to insurance brokerUSD $2,781
Total amount of fees paid to insurance companyUSD $2,998
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,781
Amount paid for insurance broker fees2998
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGE600426
Policy instance 6
Insurance contract or identification numberSGE600426
Number of Individuals Covered141
Insurance policy start date2018-05-01
Insurance policy end date2019-05-01
Total amount of commissions paid to insurance brokerUSD $3,751
Total amount of fees paid to insurance companyUSD $2,877
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,751
Amount paid for insurance broker fees2877
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberNYK700161
Policy instance 5
Insurance contract or identification numberNYK700161
Number of Individuals Covered145
Insurance policy start date2017-05-01
Insurance policy end date2018-05-01
Total amount of commissions paid to insurance brokerUSD $2,682
Total amount of fees paid to insurance companyUSD $1,732
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,682
Insurance broker organization code?3
Amount paid for insurance broker fees1732
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker namePROFESSIONAL GROUP PLANS
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered217
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of fees paid to insurance companyUSD $100,668
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,639,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees54458
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?3
Insurance broker nameHEALTHY BUSINESS GROUP LLC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGE600426
Policy instance 6
Insurance contract or identification numberSGE600426
Number of Individuals Covered145
Insurance policy start date2017-05-01
Insurance policy end date2018-05-01
Total amount of commissions paid to insurance brokerUSD $3,666
Total amount of fees paid to insurance companyUSD $1,666
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,666
Amount paid for insurance broker fees1666
Additional information about fees paid to insurance brokerSALES & SERVICE OVERRIDE
Insurance broker organization code?3
Insurance broker namePROFESSIONAL GROUP PLANS
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered72
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,677
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,677
Insurance broker organization code?3
Insurance broker namePAUL SHEPHERD
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered129
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,498
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $15,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,498
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered145
Insurance policy start date2017-02-01
Insurance policy end date2018-02-01
Total amount of fees paid to insurance companyUSD $9
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees9
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered106
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of fees paid to insurance companyUSD $43,405
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,099,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees43405
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT PAYMENTS
Insurance broker organization code?3
Insurance broker namePROFESSIONAL GROUP PLANS, INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered110
Insurance policy start date2015-02-01
Insurance policy end date2016-02-01
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered118
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $396
Total amount of fees paid to insurance companyUSD $4
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $396
Amount paid for insurance broker fees4
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered66
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $1,472
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,472
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered112
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $12,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered63
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of fees paid to insurance companyUSD $1,249
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1249
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered99
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of fees paid to insurance companyUSD $35,146
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,697,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees35146
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
Insurance broker namePROFESSIONAL GROUP PLANS, INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered107
Insurance policy start date2014-02-01
Insurance policy end date2015-02-01
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3335916
Policy instance 4
Insurance contract or identification number3335916
Number of Individuals Covered97
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of fees paid to insurance companyUSD $38,781
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,507,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees38781
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
Insurance broker namePROFESSIONAL GROUP PLANS, INC
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 3
Insurance contract or identification number500248
Number of Individuals Covered54
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $1,221
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,221
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 2
Insurance contract or identification number302327
Number of Individuals Covered90
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered109
Insurance policy start date2013-02-01
Insurance policy end date2014-02-01
Other welfare benefits providedACCIDENTAL DEATH
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 2
Insurance contract or identification number500248
Number of Individuals Covered54
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,168
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,168
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 4
Insurance contract or identification numberABY960079
Number of Individuals Covered105
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $346
Total amount of fees paid to insurance companyUSD $1
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $346
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerSUPP COMMISSION AND OVERRIDE
Insurance broker organization code?3
Insurance broker nameWILLIS OF NEW YORK INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0716247
Policy instance 3
Insurance contract or identification number0716247
Number of Individuals Covered268
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number3335916
Policy instance 1
Insurance contract or identification number3335916
Number of Individuals Covered93
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of fees paid to insurance companyUSD $27,866
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,393,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees27866
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
Insurance broker namePROFESSIONAL GROUP PLANS, INC.
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number11-3051991
Policy instance 1
Insurance contract or identification number11-3051991
Number of Individuals Covered100
Insurance policy start date2011-05-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $87
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract number500248
Policy instance 2
Insurance contract or identification number500248
Number of Individuals Covered40
Insurance policy start date2011-06-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $925
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract numberSM00901
Policy instance 3
Insurance contract or identification numberSM00901
Number of Individuals Covered249
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $4,359
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,503,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0716247
Policy instance 4
Insurance contract or identification number0716247
Number of Individuals Covered107
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $342
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $62,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 5
Insurance contract or identification numberABY960079
Number of Individuals Covered116
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of fees paid to insurance companyUSD $239
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberABY960079
Policy instance 1
Insurance contract or identification numberABY960079
Number of Individuals Covered116
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $5
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 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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 )
Policy contract numberSUP001 002 COB
Policy instance 2
Insurance contract or identification numberSUP001 002 COB
Number of Individuals Covered101
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $1,115
Total amount of fees paid to insurance companyUSD $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 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 $11,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract numberSM00901
Policy instance 3
Insurance contract or identification numberSM00901
Number of Individuals Covered266
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $52,424
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
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 $1,326,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number716247
Policy instance 5
Insurance contract or identification number716247
Number of Individuals Covered111
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $4,091
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Vision Insurance Welfare BenefitNo
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 $82,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302327
Policy instance 4
Insurance contract or identification number302327
Number of Individuals Covered116
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $1,338
Total amount of fees paid to insurance companyUSD $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 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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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