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FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 401k Plan overview

Plan NameFIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN
Plan identification number 001

FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
  • Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
  • Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
  • Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

FIFTH AVENUE ICE CREAM OF NEVADA, INC. has sponsored the creation of one or more 401k plans.

Company Name:FIFTH AVENUE ICE CREAM OF NEVADA, INC.
Employer identification number (EIN):223228763
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Additional information about FIFTH AVENUE ICE CREAM OF NEVADA, INC.

Jurisdiction of Incorporation: Nevada Department of State
Incorporation Date: 1993-04-16
Company Identification Number: 19931042534
Legal Registered Office Address: 7251 W SAHARA AVE

LAS VEGAS
United States of America (USA)
89117

More information about FIFTH AVENUE ICE CREAM OF NEVADA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0012022-01-01
0012021-01-01
0012020-01-01
0012019-07-01

Plan Statistics for FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN

401k plan membership statisitcs for FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN

Measure Date Value
2022: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01366
Total number of active participants reported on line 7a of the Form 55002022-01-01403
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-013
Total of all active and inactive participants2022-01-01406
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2022-01-010
Total participants2022-01-01406
Number of participants with account balances2022-01-0123
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2022-01-010
2021: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01481
Total number of active participants reported on line 7a of the Form 55002021-01-01306
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-015
Total of all active and inactive participants2021-01-01311
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2021-01-010
Total participants2021-01-01311
Number of participants with account balances2021-01-0126
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2021-01-010
2020: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01445
Total number of active participants reported on line 7a of the Form 55002020-01-01468
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-012
Total of all active and inactive participants2020-01-01470
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2020-01-010
Total participants2020-01-01470
Number of participants with account balances2020-01-0127
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2020-01-013
2019: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01455
Total number of active participants reported on line 7a of the Form 55002019-07-01379
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-011
Total of all active and inactive participants2019-07-01380
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2019-07-010
Total participants2019-07-01380
Number of participants with account balances2019-07-0122
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2019-07-010

Financial Data on FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN

Measure Date Value
2022 : FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$13,754
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$12,508
Total income from all sources (including contributions)2022-12-31$59,382
Total loss/gain on sale of assets2022-12-31$0
Total of all expenses incurred2022-12-31$9,709
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$9,584
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$101,607
Value of total assets at end of year2022-12-31$277,210
Value of total assets at beginning of year2022-12-31$226,291
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$125
Total interest from all sources2022-12-31$196
Total dividends received (eg from common stock, registered investment company shares)2022-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$1,000,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$76,607
Participant contributions at end of year2022-12-31$6,334
Participant contributions at beginning of year2022-12-31$6,284
Participant contributions at end of year2022-12-31$0
Participant contributions at beginning of year2022-12-31$3,160
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2022-12-31$13,754
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2022-12-31$12,508
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$49,673
Value of net assets at end of year (total assets less liabilities)2022-12-31$263,456
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$213,783
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Value of interest in pooled separate accounts at end of year2022-12-31$235,431
Value of interest in pooled separate accounts at beginning of year2022-12-31$186,857
Interest on participant loans2022-12-31$196
Income. Interest from loans (other than to participants)2022-12-31$0
Interest earned on other investments2022-12-31$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2022-12-31$10,445
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2022-12-31$4,990
Net investment gain/loss from pooled separate accounts2022-12-31$-42,421
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$25,000
Employer contributions (assets) at end of year2022-12-31$25,000
Employer contributions (assets) at beginning of year2022-12-31$25,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-12-31$9,584
Contract administrator fees2022-12-31$125
Did the plan have assets held for investment2022-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Disclaimer
Accountancy firm name2022-12-31CITRIN COOPERMAN & COMPANY LLP
Accountancy firm EIN2022-12-31222428965
2021 : FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$12,508
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$7,549
Total income from all sources (including contributions)2021-12-31$119,534
Total loss/gain on sale of assets2021-12-31$0
Total of all expenses incurred2021-12-31$12,202
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$11,952
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$102,123
Value of total assets at end of year2021-12-31$226,291
Value of total assets at beginning of year2021-12-31$114,000
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$250
Total interest from all sources2021-12-31$149
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$1,000,000
If this is an individual account plan, was there a blackout period2021-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2021-12-31$0
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$77,123
Participant contributions at end of year2021-12-31$6,284
Participant contributions at end of year2021-12-31$3,160
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2021-12-31$12,508
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2021-12-31$7,549
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$107,332
Value of net assets at end of year (total assets less liabilities)2021-12-31$213,783
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$106,451
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Value of interest in pooled separate accounts at end of year2021-12-31$186,857
Value of interest in pooled separate accounts at beginning of year2021-12-31$110,459
Interest on participant loans2021-12-31$149
Income. Interest from loans (other than to participants)2021-12-31$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2021-12-31$4,990
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2021-12-31$3,541
Net investment gain/loss from pooled separate accounts2021-12-31$17,262
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$25,000
Employer contributions (assets) at end of year2021-12-31$25,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$11,952
Contract administrator fees2021-12-31$250
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Disclaimer
Accountancy firm name2021-12-31CITRIN COOPERMAN & COMPANY LLP
Accountancy firm EIN2021-12-31222428965
2020 : FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$7,549
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$0
Total income from all sources (including contributions)2020-12-31$71,545
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$26,997
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$4,718
Value of total corrective distributions2020-12-31$22,129
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$56,818
Value of total assets at end of year2020-12-31$114,000
Value of total assets at beginning of year2020-12-31$61,903
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$150
Total interest from all sources2020-12-31$3
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31No
If this is an individual account plan, was there a blackout period2020-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2020-12-31$0
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$31,818
Participant contributions at end of year2020-12-31$0
Participant contributions at beginning of year2020-12-31$2,162
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2020-12-31$7,549
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$44,548
Value of net assets at end of year (total assets less liabilities)2020-12-31$106,451
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$61,903
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Value of interest in pooled separate accounts at end of year2020-12-31$110,459
Value of interest in pooled separate accounts at beginning of year2020-12-31$55,523
Interest on participant loans2020-12-31$0
Income. Interest from loans (other than to participants)2020-12-31$0
Interest earned on other investments2020-12-31$3
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2020-12-31$3,541
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2020-12-31$4,218
Net investment gain/loss from registered investment companies (e.g. mutual funds)2020-12-31$0
Net investment gain/loss from pooled separate accounts2020-12-31$14,724
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$25,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$4,718
Contract administrator fees2020-12-31$150
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31CITRIN COOPERMAN & COMPANY LLP
Accountancy firm EIN2020-12-31222428965
2019 : FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total income from all sources (including contributions)2019-12-31$61,903
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$0
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$59,041
Value of total assets at end of year2019-12-31$61,903
Value of total assets at beginning of year2019-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$0
Total interest from all sources2019-12-31$3
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$1,000,000
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$59,041
Participant contributions at end of year2019-12-31$2,162
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$61,903
Value of net assets at end of year (total assets less liabilities)2019-12-31$61,903
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Value of interest in pooled separate accounts at end of year2019-12-31$55,523
Interest on participant loans2019-12-31$0
Interest earned on other investments2019-12-31$3
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2019-12-31$4,218
Net investment gain/loss from pooled separate accounts2019-12-31$2,859
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No

Form 5500 Responses for FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN

2022: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: FIFTH AVENUE ICE CREAM OF NEVADA INC 401(K) PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01First time form 5500 has been submittedYes
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – TrustYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number25255
Policy instance 1
Insurance contract or identification number25255
Number of Individuals Covered23
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,575
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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?No
Amount paid for insurance broker fees1575
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number25255
Policy instance 1
Insurance contract or identification number25255
Number of Individuals Covered26
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,078
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees1078
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number25255
Policy instance 1
Insurance contract or identification number25255
Number of Individuals Covered27
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $581
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees581
Additional information about fees paid to insurance brokerSERV FEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract number25255
Policy instance 1
Insurance contract or identification number25255
Number of Individuals Covered22
Insurance policy start date2019-02-22
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $104
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?Yes
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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?No
Amount paid for insurance broker fees104
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3

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