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FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 401k Plan overview

Plan NameFAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE
Plan identification number 504

FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

FAZOLIS RESTAURANT GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name:FAZOLIS RESTAURANT GROUP, INC.
Employer identification number (EIN):205593113
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042022-07-01TISH CHISM2023-12-18
5042021-07-01TISH CHISM2022-12-28
5042020-07-01TISH CHISM2022-01-28
5042019-07-01TISH CHISM2021-01-19
5042018-07-01TISH CHISM2020-02-07
5042017-07-01
5042016-07-01
5042015-07-01DAVE CRAIG
5042014-07-01DAVE CRAIG
5042014-04-01DAVE CRAIG
5042013-04-01DAVE CRAIG
5042012-04-01DAVE CRAIG
5042011-04-01DAVID CRAIG
5042010-04-01DAVE CRAIG
5042009-04-01DAVID CRAIG RODNEY LEE2011-01-13

Plan Statistics for FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

401k plan membership statisitcs for FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Measure Date Value
2022: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2022 401k membership
Total participants, beginning-of-year2022-07-01185
Total number of active participants reported on line 7a of the Form 55002022-07-01185
Number of retired or separated participants receiving benefits2022-07-010
Number of other retired or separated participants entitled to future benefits2022-07-010
Total of all active and inactive participants2022-07-01185
Number of employers contributing to the scheme2022-07-010
2021: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2021 401k membership
Total participants, beginning-of-year2021-07-01185
Total number of active participants reported on line 7a of the Form 55002021-07-01185
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01185
Number of employers contributing to the scheme2021-07-010
2020: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2020 401k membership
Total participants, beginning-of-year2020-07-01175
Total number of active participants reported on line 7a of the Form 55002020-07-01185
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01185
Number of employers contributing to the scheme2020-07-010
2019: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2019 401k membership
Total participants, beginning-of-year2019-07-01179
Total number of active participants reported on line 7a of the Form 55002019-07-01164
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01164
Number of employers contributing to the scheme2019-07-010
2018: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2018 401k membership
Total participants, beginning-of-year2018-07-01180
Total number of active participants reported on line 7a of the Form 55002018-07-01180
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01180
Number of employers contributing to the scheme2018-07-010
2017: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2017 401k membership
Total participants, beginning-of-year2017-07-01318
Total number of active participants reported on line 7a of the Form 55002017-07-01318
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01318
2016: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2016 401k membership
Total participants, beginning-of-year2016-07-01331
Total number of active participants reported on line 7a of the Form 55002016-07-01318
Number of retired or separated participants receiving benefits2016-07-010
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01318
2015: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2015 401k membership
Total participants, beginning-of-year2015-07-01335
Total number of active participants reported on line 7a of the Form 55002015-07-01347
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01347
2014: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2014 401k membership
Total participants, beginning-of-year2014-07-01340
Total number of active participants reported on line 7a of the Form 55002014-07-01324
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01324
Total participants, beginning-of-year2014-04-01344
Total number of active participants reported on line 7a of the Form 55002014-04-01340
Number of retired or separated participants receiving benefits2014-04-010
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01340
2013: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2013 401k membership
Total participants, beginning-of-year2013-04-01329
Total number of active participants reported on line 7a of the Form 55002013-04-01332
Number of retired or separated participants receiving benefits2013-04-010
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01332
2012: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2012 401k membership
Total participants, beginning-of-year2012-04-01322
Total number of active participants reported on line 7a of the Form 55002012-04-01322
Number of retired or separated participants receiving benefits2012-04-010
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01322
2011: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2011 401k membership
Total participants, beginning-of-year2011-04-01323
Total number of active participants reported on line 7a of the Form 55002011-04-01322
Number of retired or separated participants receiving benefits2011-04-010
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-01322
2010: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2010 401k membership
Total participants, beginning-of-year2010-04-01324
Total number of active participants reported on line 7a of the Form 55002010-04-01327
Number of retired or separated participants receiving benefits2010-04-010
Number of other retired or separated participants entitled to future benefits2010-04-010
Total of all active and inactive participants2010-04-01327
2009: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2009 401k membership
Total participants, beginning-of-year2009-04-01325
Total number of active participants reported on line 7a of the Form 55002009-04-01341
Number of retired or separated participants receiving benefits2009-04-010
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01341
Total participants2009-04-01341

Form 5500 Responses for FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

2022: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan funding arrangement – General assets of the sponsorYes
2022-07-01Plan benefit arrangement – InsuranceYes
2022-07-01Plan benefit arrangement – General assets of the sponsorYes
2021: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – General assets of the sponsorYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – General assets of the sponsorYes
2017: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan funding arrangement – General assets of the sponsorYes
2017-07-01Plan benefit arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – General assets of the sponsorYes
2016: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan funding arrangement – General assets of the sponsorYes
2016-07-01Plan benefit arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – General assets of the sponsorYes
2015: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan funding arrangement – General assets of the sponsorYes
2014-07-01Plan benefit arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – General assets of the sponsorYes
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – General assets of the sponsorYes
2013: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan funding arrangement – General assets of the sponsorYes
2013-04-01Plan benefit arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – General assets of the sponsorYes
2012: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan funding arrangement – General assets of the sponsorYes
2012-04-01Plan benefit arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – General assets of the sponsorYes
2011: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan funding arrangement – General assets of the sponsorYes
2011-04-01Plan benefit arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – General assets of the sponsorYes
2010: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan funding arrangement – General assets of the sponsorYes
2010-04-01Plan benefit arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – General assets of the sponsorYes
2009: FAZOLIS RESTAURANT GROUP, INC. MEMBER LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered185
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $2,510
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $42,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,510
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered185
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $3,654
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $52,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,654
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered185
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK963492
Policy instance 2
Insurance contract or identification numberOK963492
Number of Individuals Covered164
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $200
Total amount of fees paid to insurance companyUSD $144
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $6,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $110
Amount paid for insurance broker fees287
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered164
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $2,880
Total amount of fees paid to insurance companyUSD $739
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,652
Amount paid for insurance broker fees1479
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered180
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $3,110
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $49,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,110
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered318
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $6,914
Total amount of fees paid to insurance companyUSD $1,864
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $83,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,311
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker nameALTERITY GROUP
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered347
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $6,683
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $72,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,510
Insurance broker organization code?3
Insurance broker nameALTERITY GROUP
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered322
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $8,733
Total amount of fees paid to insurance companyUSD $3,048
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $93,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,938
Insurance broker organization code?3
Amount paid for insurance broker fees3048
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker nameALTERITY GROUP
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered340
Insurance policy start date2014-04-01
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered322
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $5,939
Total amount of fees paid to insurance companyUSD $1,322
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $63,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,026
Insurance broker organization code?3
Amount paid for insurance broker fees1322
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker nameALTERITY GROUP
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered322
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $7,093
Total amount of fees paid to insurance companyUSD $1,291
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $75,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,827
Insurance broker organization code?3
Amount paid for insurance broker fees1291
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker nameALTERITY GROUP
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered322
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $6,502
Total amount of fees paid to insurance companyUSD $536
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $74,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX961907
Policy instance 1
Insurance contract or identification numberFLX961907
Number of Individuals Covered327
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $4,657
Total amount of fees paid to insurance companyUSD $864
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $70,193
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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