401k Plan data: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN plan

CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 401k Plan overview

Plan Name	CONVERGEONE HOLDINGS CORP. BENEFIT PLAN
Plan identification number	506

CONVERGEONE HOLDINGS CORP. BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

CONVERGEONE HOLDINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name: CONVERGEONE HOLDINGS, INC.

Employer identification number (EIN): 204202326

NAIC Classification: 517000

Additional information about CONVERGEONE HOLDINGS, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 4096344

More information about CONVERGEONE HOLDINGS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CONVERGEONE HOLDINGS CORP. BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2020-01-01
506 2019-01-01
506 2018-01-01
506 2017-01-01 NATALIE ANDERSON
506 2016-01-01 NATALIE ANDERSON
506 2015-01-01 NATALIE ANDERSON

Plan Statistics for CONVERGEONE HOLDINGS CORP. BENEFIT PLAN

401k plan membership statisitcs for CONVERGEONE HOLDINGS CORP. BENEFIT PLAN

Measure Date Value
2020: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 2,609
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 2,355
Number of retired or separated participants receiving benefits 2020-01-01 48
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 2,403
2019: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 2,526
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 2,556
Number of retired or separated participants receiving benefits 2019-01-01 53
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 2,609
2018: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 1,902
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 2,484
Number of retired or separated participants receiving benefits 2018-01-01 42
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 2,526
2017: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 1,357
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 1,841
Number of retired or separated participants receiving benefits 2017-01-01 61
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 1,902
2016: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,011
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,348
Number of retired or separated participants receiving benefits 2016-01-01 9
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 1,357
2015: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,011
Total of all active and inactive participants 2015-01-01 1,011

Measure	Date	Value
2020: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	2,609
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	2,355
Number of retired or separated participants receiving benefits	2020-01-01	48
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	2,403
2019: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	2,526
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	2,556
Number of retired or separated participants receiving benefits	2019-01-01	53
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	2,609
2018: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	1,902
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	2,484
Number of retired or separated participants receiving benefits	2018-01-01	42
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	2,526
2017: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	1,357
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	1,841
Number of retired or separated participants receiving benefits	2017-01-01	61
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	1,902
2016: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,011
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,348
Number of retired or separated participants receiving benefits	2016-01-01	9
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	1,357
2015: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,011
Total of all active and inactive participants	2015-01-01	1,011

Form 5500 Responses for CONVERGEONE HOLDINGS CORP. BENEFIT PLAN

2020: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: CONVERGEONE HOLDINGS CORP. BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

203801

Policy instance

Insurance contract or identification number	203801
Number of Individuals Covered	458
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,278
Other welfare benefits provided	LEGAL SERVICES PLAN MEMBERSHIP
Welfare Benefit Premiums Paid to Carrier	USD $96,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,438
Insurance broker organization code?	4

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166200

Policy instance

Insurance contract or identification number	166200
Number of Individuals Covered	2355
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $39,635
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	33531
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166200

Policy instance

Insurance contract or identification number	166200
Number of Individuals Covered	675
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $147,493
Welfare Benefit Premiums Paid to Carrier	USD $258,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $135,999
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166200

Policy instance

Insurance contract or identification number	166200
Number of Individuals Covered	1769
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $7,702
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	6518
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

166200

Policy instance

Insurance contract or identification number	166200
Number of Individuals Covered	2327
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $11,624
Long Term Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9802
Additional information about fees paid to insurance broker	ADMINISTRATION
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201274

Policy instance

Insurance contract or identification number	201274
Number of Individuals Covered	4384
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $213,399
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,866,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $213,399
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

8261001,0921001

Policy instance

Insurance contract or identification number	8261001,0921001
Number of Individuals Covered	3796
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $33,756
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $307,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,756
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605849

Policy instance

Insurance contract or identification number	605849
Number of Individuals Covered	43
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $293,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233836

Policy instance

Insurance contract or identification number	233836
Number of Individuals Covered	135
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,011,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099082325

Policy instance

Insurance contract or identification number	000099082325
Number of Individuals Covered	2110
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $1,281
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $732
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10109998

Policy instance

Insurance contract or identification number	10109998
Number of Individuals Covered	2542
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $12,643
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $356,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	12643
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201274

Policy instance

Insurance contract or identification number	201274
Number of Individuals Covered	4929
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $254,147
Total amount of fees paid to insurance company	USD $39,600
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,984,759
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $254,147
Amount paid for insurance broker fees	39600
Additional information about fees paid to insurance broker	INCENTIVE PAYMENTS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97378261001

Policy instance

Insurance contract or identification number	97378261001
Number of Individuals Covered	4058
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $33,294
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $334,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,294
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605849

Policy instance

Insurance contract or identification number	605849
Number of Individuals Covered	28
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $206,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233836

Policy instance

Insurance contract or identification number	233836
Number of Individuals Covered	39
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $253,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99082325

Policy instance

Insurance contract or identification number	99082325
Number of Individuals Covered	2110
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,232
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $3,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $704
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

203801

Policy instance

Insurance contract or identification number	203801
Number of Individuals Covered	504
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $16,142
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $94,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,394
Insurance broker organization code?	4

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

10239000

Policy instance

Insurance contract or identification number	10239000
Number of Individuals Covered	181
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,320
Total amount of fees paid to insurance company	USD $279
Other welfare benefits provided	STATUTORY DISABILITY AND FAMILY LEA
Welfare Benefit Premiums Paid to Carrier	USD $26,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,320
Insurance broker organization code?	3
Amount paid for insurance broker fees	279
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10211920

Policy instance

Insurance contract or identification number	10211920
Number of Individuals Covered	1928
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $15,867
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $299,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	15867
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

400110041

Policy instance

Insurance contract or identification number	400110041
Number of Individuals Covered	2281
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $21,761
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $893,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	21761
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10109997

Policy instance

Insurance contract or identification number	10109997
Number of Individuals Covered	2556
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of fees paid to insurance company	USD $5,463
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $144,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5463
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010109997

Policy instance

Insurance contract or identification number	000010109997
Number of Individuals Covered	2538
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $3,010
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $145,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3010
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400110041

Policy instance

Insurance contract or identification number	000400110041
Number of Individuals Covered	2274
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $11,756
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $742,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	11756
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010211920

Policy instance

Insurance contract or identification number	000010211920
Number of Individuals Covered	1870
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $8,747
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $286,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	8747
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010109998

Policy instance

Insurance contract or identification number	000010109998
Number of Individuals Covered	2467
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $7,225
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7225
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201274

Policy instance

Insurance contract or identification number	201274
Number of Individuals Covered	4698
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $82,995
Total amount of fees paid to insurance company	USD $18,000
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $82,995
Amount paid for insurance broker fees	18000
Additional information about fees paid to insurance broker	INCENTIVE PAYMENTS
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97378261001

Policy instance

Insurance contract or identification number	97378261001
Number of Individuals Covered	3885
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $32,652
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $307,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,252
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

605849

Policy instance

Insurance contract or identification number	605849
Number of Individuals Covered	32
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $168,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

233836

Policy instance

Insurance contract or identification number	233836
Number of Individuals Covered	42
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $233,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99082325

Policy instance

Insurance contract or identification number	99082325
Number of Individuals Covered	2110
Insurance policy start date	2017-08-01
Insurance policy end date	2018-07-31
Total amount of commissions paid to insurance broker	USD $1,075
Other welfare benefits provided	BTA
Welfare Benefit Premiums Paid to Carrier	USD $3,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $614
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

ERLL18101421001

Policy instance

Insurance contract or identification number	ERLL18101421001
Number of Individuals Covered	4698
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of fees paid to insurance company	USD $71,460
Welfare Benefit Premiums Paid to Carrier	USD $1,429,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	71460
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010109997

Policy instance

Insurance contract or identification number	000010109997
Number of Individuals Covered	1841
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $2,685
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $100,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2685
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000400110041

Policy instance

Insurance contract or identification number	000400110041
Number of Individuals Covered	895
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $10,250
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $391,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	10250
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010211920

Policy instance

Insurance contract or identification number	000010211920
Number of Individuals Covered	1378
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $3,522
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $184,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3522
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010109998

Policy instance

Insurance contract or identification number	000010109998
Number of Individuals Covered	1825
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $5,996
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $240,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5996
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )

Policy contract number

201274

Policy instance

Insurance contract or identification number	201274
Number of Individuals Covered	3586
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $50,912
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $894,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,912
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97378261001

Policy instance

Insurance contract or identification number	97378261001
Number of Individuals Covered	2844
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $15,820
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $174,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,820
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9737826

Policy instance

Insurance contract or identification number	9737826
Number of Individuals Covered	1480
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,601
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $116,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,601
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10109997

Policy instance

Insurance contract or identification number	10109997
Number of Individuals Covered	1011
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $25,918
Total amount of fees paid to insurance company	USD $16,836
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL 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 Carrier	USD $723,517
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,390
Amount paid for insurance broker fees	16836
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

Potentially related plans

CONVERGEONE HOLDINGS, INC. BENEFIT PLAN [EIN = 814619427]

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Company Name:	CONVERGEONE HOLDINGS, INC.
Employer identification number (EIN):	204202326
NAIC Classification:	517000

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	4096344