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ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan NameATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN
Plan identification number 501

ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

ATTENTIVE HOME CARE, INC. has sponsored the creation of one or more 401k plans.

Company Name:ATTENTIVE HOME CARE, INC.
Employer identification number (EIN):113680445
NAIC Classification:621610
NAIC Description:Home Health Care Services

Additional information about ATTENTIVE HOME CARE, INC.

Jurisdiction of Incorporation: Virginia Secretary of State
Incorporation Date: 2016-08-02
Company Identification Number: 0807925
Legal Registered Office Address: 13578 CEDAR RUN LN

OAK HILL
United States of America (USA)
20171

More information about ATTENTIVE HOME CARE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012018-01-01
5012017-01-01JENNIFER E. RIVA-KIRK2018-10-03 JENNIFER E. RIVA-KIRK2018-10-03
5012016-01-01JENNIFER RIVA-KIRK2017-10-13 JENNIFER RIVA-KIRK2017-10-13
5012015-01-01DERRICK QUAN DERRICK QUAN2016-10-17
5012014-01-01JOHN KUVEIKIS
5012013-01-01YELENA PUSTILNIK
5012012-10-01YELENA PUSTILNIK YELENA PUSTILNIK2013-10-15

Plan Statistics for ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN

Measure Date Value
2015: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01127
Total number of active participants reported on line 7a of the Form 55002015-01-01131
Total of all active and inactive participants2015-01-01131
2014: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01273
Total number of active participants reported on line 7a of the Form 55002014-01-01127
Total of all active and inactive participants2014-01-01127
2013: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01324
Total number of active participants reported on line 7a of the Form 55002013-01-01273
Total of all active and inactive participants2013-01-01273
2012: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01291
Total number of active participants reported on line 7a of the Form 55002012-10-01324
Number of retired or separated participants receiving benefits2012-10-010
Number of other retired or separated participants entitled to future benefits2012-10-010
Total of all active and inactive participants2012-10-01324

Financial Data on ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN

Measure Date Value
2015 : ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets2015-12-31$0
Total transfer of assets from this plan2015-12-31$130,000
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$213,227
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$239,618
Total income from all sources (including contributions)2015-12-31$46,665
Total loss/gain on sale of assets2015-12-31$0
Total of all expenses incurred2015-12-31$47,128
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2015-12-31$16,662
Total contributions o plan (from employers,participants, others, non cash contrinutions)2015-12-31$46,665
Value of total assets at end of year2015-12-31$120,854
Value of total assets at beginning of year2015-12-31$277,708
Total of administrative expenses incurred including professional, contract, advisory and management fees2015-12-31$30,466
Total interest from all sources2015-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2015-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-12-31Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan2015-12-31$0
Administrative expenses professional fees incurred2015-12-31$12,250
Was this plan covered by a fidelity bond2015-12-31Yes
Value of fidelity bond cover2015-12-31$20,000
If this is an individual account plan, was there a blackout period2015-12-31No
Were there any nonexempt tranactions with any party-in-interest2015-12-31No
Value of other receiveables (less allowance for doubtful accounts) at end of year2015-12-31$25,000
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2015-12-31$25,000
Administrative expenses (other) incurred2015-12-31$6,812
Liabilities. Value of operating payables at end of year2015-12-31$30,603
Liabilities. Value of operating payables at beginning of year2015-12-31$29,184
Total non interest bearing cash at end of year2015-12-31$95,854
Total non interest bearing cash at beginning of year2015-12-31$205,389
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Value of net income/loss2015-12-31$-463
Value of net assets at end of year (total assets less liabilities)2015-12-31$-92,373
Value of net assets at beginning of year (total assets less liabilities)2015-12-31$38,090
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Were any leases to which the plan was party in default or uncollectible2015-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2015-12-31$14,020
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-12-31No
Was there a failure to transmit to the plan any participant contributions2015-12-31No
Has the plan failed to provide any benefit when due under the plan2015-12-31No
Contributions received in cash from employer2015-12-31$46,665
Employer contributions (assets) at beginning of year2015-12-31$47,319
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2015-12-31$2,642
Contract administrator fees2015-12-31$11,404
Liabilities. Value of benefit claims payable at end of year2015-12-31$182,624
Liabilities. Value of benefit claims payable at beginning of year2015-12-31$210,434
Did the plan have assets held for investment2015-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2015-12-31No
Opinion of an independent qualified public accountant for this plan2015-12-31Unqualified
Accountancy firm name2015-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2015-12-31562552172
2014 : ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets2014-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-12-31$239,618
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-12-31$258,941
Total income from all sources (including contributions)2014-12-31$189,732
Total loss/gain on sale of assets2014-12-31$0
Total of all expenses incurred2014-12-31$186,808
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2014-12-31$118,834
Total contributions o plan (from employers,participants, others, non cash contrinutions)2014-12-31$189,732
Value of total assets at end of year2014-12-31$277,708
Value of total assets at beginning of year2014-12-31$294,107
Total of administrative expenses incurred including professional, contract, advisory and management fees2014-12-31$67,974
Total interest from all sources2014-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2014-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-12-31No
Administrative expenses professional fees incurred2014-12-31$12,507
Was this plan covered by a fidelity bond2014-12-31Yes
Value of fidelity bond cover2014-12-31$100,000
If this is an individual account plan, was there a blackout period2014-12-31No
Were there any nonexempt tranactions with any party-in-interest2014-12-31No
Value of other receiveables (less allowance for doubtful accounts) at end of year2014-12-31$25,000
Administrative expenses (other) incurred2014-12-31$30,451
Liabilities. Value of operating payables at end of year2014-12-31$29,184
Liabilities. Value of operating payables at beginning of year2014-12-31$29,905
Total non interest bearing cash at end of year2014-12-31$205,389
Total non interest bearing cash at beginning of year2014-12-31$216,740
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Value of net income/loss2014-12-31$2,924
Value of net assets at end of year (total assets less liabilities)2014-12-31$38,090
Value of net assets at beginning of year (total assets less liabilities)2014-12-31$35,166
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-12-31No
Were any leases to which the plan was party in default or uncollectible2014-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2014-12-31$61,276
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-12-31No
Was there a failure to transmit to the plan any participant contributions2014-12-31No
Has the plan failed to provide any benefit when due under the plan2014-12-31No
Contributions received in cash from employer2014-12-31$189,732
Employer contributions (assets) at end of year2014-12-31$47,319
Employer contributions (assets) at beginning of year2014-12-31$77,367
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2014-12-31$57,558
Contract administrator fees2014-12-31$25,016
Liabilities. Value of benefit claims payable at end of year2014-12-31$210,434
Liabilities. Value of benefit claims payable at beginning of year2014-12-31$229,036
Did the plan have assets held for investment2014-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2014-12-31No
Opinion of an independent qualified public accountant for this plan2014-12-31Unqualified
Accountancy firm name2014-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2014-12-31562552172
2013 : ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets2013-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-12-31$258,941
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-12-31$80,706
Total income from all sources (including contributions)2013-12-31$540,749
Total loss/gain on sale of assets2013-12-31$0
Total of all expenses incurred2013-12-31$519,284
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-12-31$363,388
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-12-31$540,749
Value of total assets at end of year2013-12-31$294,107
Value of total assets at beginning of year2013-12-31$94,407
Total of administrative expenses incurred including professional, contract, advisory and management fees2013-12-31$155,896
Total interest from all sources2013-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2013-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-12-31No
Administrative expenses professional fees incurred2013-12-31$1,993
Was this plan covered by a fidelity bond2013-12-31Yes
Value of fidelity bond cover2013-12-31$100,000
If this is an individual account plan, was there a blackout period2013-12-31No
Were there any nonexempt tranactions with any party-in-interest2013-12-31No
Administrative expenses (other) incurred2013-12-31$79,233
Liabilities. Value of operating payables at end of year2013-12-31$29,905
Liabilities. Value of operating payables at beginning of year2013-12-31$16,439
Total non interest bearing cash at end of year2013-12-31$216,740
Total non interest bearing cash at beginning of year2013-12-31$30,446
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-12-31No
Value of net income/loss2013-12-31$21,465
Value of net assets at end of year (total assets less liabilities)2013-12-31$35,166
Value of net assets at beginning of year (total assets less liabilities)2013-12-31$13,701
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2013-12-31No
Were any leases to which the plan was party in default or uncollectible2013-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2013-12-31$153,473
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-12-31No
Was there a failure to transmit to the plan any participant contributions2013-12-31No
Has the plan failed to provide any benefit when due under the plan2013-12-31No
Contributions received in cash from employer2013-12-31$540,749
Employer contributions (assets) at end of year2013-12-31$77,367
Employer contributions (assets) at beginning of year2013-12-31$63,961
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2013-12-31$209,915
Contract administrator fees2013-12-31$74,670
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32013-12-31No
Liabilities. Value of benefit claims payable at end of year2013-12-31$229,036
Liabilities. Value of benefit claims payable at beginning of year2013-12-31$64,267
Did the plan have assets held for investment2013-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2013-12-31No
Opinion of an independent qualified public accountant for this plan2013-12-31Unqualified
Accountancy firm name2013-12-31INEICH & COMPANY, LLP
Accountancy firm EIN2013-12-31562552172
2012 : ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets2012-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-12-31$53,231
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-12-31$0
Total income from all sources (including contributions)2012-12-31$146,427
Total loss/gain on sale of assets2012-12-31$0
Total of all expenses incurred2012-12-31$105,251
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2012-12-31$62,962
Total contributions o plan (from employers,participants, others, non cash contrinutions)2012-12-31$146,427
Value of total assets at end of year2012-12-31$94,407
Value of total assets at beginning of year2012-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2012-12-31$42,289
Total interest from all sources2012-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2012-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-12-31No
Was this plan covered by a fidelity bond2012-12-31Yes
Value of fidelity bond cover2012-12-31$100,000
Were there any nonexempt tranactions with any party-in-interest2012-12-31No
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2012-12-31$25,317
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2012-12-31$602
Administrative expenses (other) incurred2012-12-31$3,948
Liabilities. Value of operating payables at end of year2012-12-31$15,837
Total non interest bearing cash at end of year2012-12-31$30,446
Total non interest bearing cash at beginning of year2012-12-31$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-12-31No
Value of net income/loss2012-12-31$41,176
Value of net assets at end of year (total assets less liabilities)2012-12-31$41,176
Value of net assets at beginning of year (total assets less liabilities)2012-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2012-12-31No
Were any leases to which the plan was party in default or uncollectible2012-12-31No
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2012-12-31$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-12-31No
Was there a failure to transmit to the plan any participant contributions2012-12-31No
Has the plan failed to provide any benefit when due under the plan2012-12-31No
Contributions received in cash from employer2012-12-31$146,427
Employer contributions (assets) at end of year2012-12-31$63,961
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2012-12-31$37,645
Contract administrator fees2012-12-31$38,341
Liabilities. Value of benefit claims payable at end of year2012-12-31$36,792
Did the plan have assets held for investment2012-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-12-31No

Form 5500 Responses for ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN

2015: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – TrustYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement - TrustYes
2014: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – TrustYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement - TrustYes
2013: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedYes
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – TrustYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement - TrustYes
2012: ATTENTIVE HOME CARE, INC. HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01First time form 5500 has been submittedYes
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – TrustYes
2012-10-01Plan benefit arrangement – InsuranceYes
2012-10-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract numberSSL DENT ACH 01
Policy instance 1
Insurance contract or identification numberSSL DENT ACH 01
Number of Individuals Covered132
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 $9,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 645687
Policy instance 1
Insurance contract or identification numberGL 645687
Number of Individuals Covered268
Insurance policy start date2014-01-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $309
Total amount of fees paid to insurance companyUSD $2,637
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
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 $12,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $309
Insurance broker organization code?3
Amount paid for insurance broker fees2637
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER SERVICES
Insurance broker nameFCE BENEFIT ADMINISTRATOS, INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVAR 645885
Policy instance 2
Insurance contract or identification numberVAR 645885
Number of Individuals Covered268
Insurance policy start date2014-01-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $66
Total amount of fees paid to insurance companyUSD $567
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 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 $2,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $66
Insurance broker organization code?3
Amount paid for insurance broker fees567
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER SERVICES
Insurance broker nameFCE BENEFIT ADMINISTRATOS, INC.
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract numberSSL DENT ACH 1
Policy instance 3
Insurance contract or identification numberSSL DENT ACH 1
Number of Individuals Covered210
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $0
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 $67,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 54199 )
Policy contract number652
Policy instance 4
Insurance contract or identification number652
Number of Individuals Covered269
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $0
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
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 $3,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVAR 645885
Policy instance 2
Insurance contract or identification numberVAR 645885
Number of Individuals Covered437
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $630
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 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 $2,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees630
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER SERVICES
Insurance broker organization code?5
Insurance broker nameFCE BENEFIT ADMINISTRATOS, INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 645687
Policy instance 1
Insurance contract or identification numberGL 645687
Number of Individuals Covered437
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $63
Total amount of fees paid to insurance companyUSD $2,934
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
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 $13,647
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63
Insurance broker organization code?3
Amount paid for insurance broker fees2934
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER SERVICES
Insurance broker nameFCE BENEFIT ADMINISTRATOS, INC.
STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )
Policy contract number
Policy instance 3
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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