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SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameSOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN
Plan identification number 501

SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS 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)

401k Sponsoring company profile

SOUTH TEXAS OILFIELD SOLUTIONS, LLC has sponsored the creation of one or more 401k plans.

Company Name:SOUTH TEXAS OILFIELD SOLUTIONS, LLC
Employer identification number (EIN):138371050
NAIC Classification:211110
NAIC Description: Oil and Gas Extraction, Oil

Additional information about SOUTH TEXAS OILFIELD SOLUTIONS, LLC

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2010-09-28
Company Identification Number: 0801323898
Legal Registered Office Address: PO BOX 3320

ALICE
United States of America (USA)
78333

More information about SOUTH TEXAS OILFIELD SOLUTIONS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-12-01CRYSTAL CRUZ2023-07-06
5012020-12-01CRYSTAL CRUZ2022-06-29
5012019-12-01CRYSTAL CRUZ2021-07-08
5012018-12-01CRYSTAL CRUZ2020-08-03
5012017-12-01CLINT CARPENTER2021-02-21
5012017-11-01CLINT CARPENTER2021-02-21
5012016-11-01CLINT CARPENTER2021-02-21
5012016-11-01CLINT CARPENTER2021-02-21

Plan Statistics for SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN

Measure Date Value
2021: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-12-01106
Total number of active participants reported on line 7a of the Form 55002021-12-01110
Total of all active and inactive participants2021-12-01110
2020: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-12-01181
Total number of active participants reported on line 7a of the Form 55002020-12-01182
Total of all active and inactive participants2020-12-01182
2019: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-12-01220
Total number of active participants reported on line 7a of the Form 55002019-12-01208
Total of all active and inactive participants2019-12-01208
2018: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-12-01200
Total number of active participants reported on line 7a of the Form 55002018-12-01220
Total of all active and inactive participants2018-12-01220
2017: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01125
Total number of active participants reported on line 7a of the Form 55002017-12-01290
Total of all active and inactive participants2017-12-01290
Total participants, beginning-of-year2017-11-01121
Total number of active participants reported on line 7a of the Form 55002017-11-01125
Total of all active and inactive participants2017-11-01125
2016: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01121
Total number of active participants reported on line 7a of the Form 55002016-11-01121
Total of all active and inactive participants2016-11-01121

Form 5500 Responses for SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN

2021: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-12-01Type of plan entitySingle employer plan
2021-12-01Submission has been amendedNo
2021-12-01This submission is the final filingNo
2021-12-01This return/report is a short plan year return/report (less than 12 months)No
2021-12-01Plan is a collectively bargained planNo
2021-12-01Plan funding arrangement – InsuranceYes
2021-12-01Plan benefit arrangement – InsuranceYes
2020: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-12-01Type of plan entitySingle employer plan
2020-12-01Submission has been amendedNo
2020-12-01This submission is the final filingNo
2020-12-01This return/report is a short plan year return/report (less than 12 months)No
2020-12-01Plan is a collectively bargained planNo
2020-12-01Plan funding arrangement – InsuranceYes
2020-12-01Plan benefit arrangement – InsuranceYes
2019: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-12-01Type of plan entitySingle employer plan
2019-12-01Submission has been amendedNo
2019-12-01This submission is the final filingNo
2019-12-01This return/report is a short plan year return/report (less than 12 months)No
2019-12-01Plan is a collectively bargained planNo
2019-12-01Plan funding arrangement – InsuranceYes
2019-12-01Plan benefit arrangement – InsuranceYes
2018: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-12-01Type of plan entitySingle employer plan
2018-12-01Submission has been amendedNo
2018-12-01This submission is the final filingNo
2018-12-01This return/report is a short plan year return/report (less than 12 months)No
2018-12-01Plan is a collectively bargained planNo
2018-12-01Plan funding arrangement – InsuranceYes
2018-12-01Plan benefit arrangement – InsuranceYes
2017: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01Submission has been amendedNo
2017-12-01This submission is the final filingNo
2017-12-01This return/report is a short plan year return/report (less than 12 months)No
2017-12-01Plan is a collectively bargained planNo
2017-12-01Plan funding arrangement – InsuranceYes
2017-12-01Plan benefit arrangement – InsuranceYes
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – InsuranceYes
2016: SOUTH TEXAS OILFIELD SOLUTIONS EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01First time form 5500 has been submittedYes
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number926744
Policy instance 2
Insurance contract or identification number926744
Number of Individuals Covered277
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $6,347
Total amount of fees paid to insurance companyUSD $66,332
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
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 $959,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,347
Amount paid for insurance broker fees59560
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number309843
Policy instance 1
Insurance contract or identification number309843
Number of Individuals Covered196
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $1,160
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,160
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF023521
Policy instance 2
Insurance contract or identification numberF023521
Number of Individuals Covered202
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $2,677
Total amount of fees paid to insurance companyUSD $1,651
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,275
Amount paid for insurance broker fees1651
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number251346
Policy instance 1
Insurance contract or identification number251346
Number of Individuals Covered197
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $47,998
Total amount of fees paid to insurance companyUSD $1,579
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $1,050,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,159
Amount paid for insurance broker fees1579
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF023521
Policy instance 2
Insurance contract or identification numberF023521
Number of Individuals Covered187
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $2,712
Total amount of fees paid to insurance companyUSD $1,528
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,712
Amount paid for insurance broker fees1528
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number251346
Policy instance 1
Insurance contract or identification number251346
Number of Individuals Covered208
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $51,670
Total amount of fees paid to insurance companyUSD $3,777
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $1,047,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,670
Amount paid for insurance broker fees3777
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF023521
Policy instance 2
Insurance contract or identification numberF023521
Number of Individuals Covered219
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $2,660
Total amount of fees paid to insurance companyUSD $1,309
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,660
Amount paid for insurance broker fees1309
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number251346
Policy instance 1
Insurance contract or identification number251346
Number of Individuals Covered222
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $51,222
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $943,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,222
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number913621
Policy instance 1
Insurance contract or identification number913621
Number of Individuals Covered290
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $6,097
Total amount of fees paid to insurance companyUSD $35,645
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $734,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,478
Amount paid for insurance broker fees26280
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGAE40344
Policy instance 1
Insurance contract or identification numberGAE40344
Number of Individuals Covered125
Insurance policy start date2017-11-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $74
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $74
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberGAE40344
Policy instance 1
Insurance contract or identification numberGAE40344
Number of Individuals Covered121
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $75
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,940
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75
Insurance broker organization code?3

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