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BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 401k Plan overview

Plan NameBREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN
Plan identification number 501

BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)

401k Sponsoring company profile

BREWERY PRODUCTS COMPANY has sponsored the creation of one or more 401k plans.

Company Name:BREWERY PRODUCTS COMPANY
Employer identification number (EIN):231518051
NAIC Classification:424800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01
5012021-06-01
5012020-06-01
5012019-06-01
5012018-06-01
5012017-06-01DEREK SIEGEL
5012016-06-01DEREK SIEGEL
5012015-06-01SUSAN K JOINES

Plan Statistics for BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN

401k plan membership statisitcs for BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN

Measure Date Value
2022: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-0149
Total number of active participants reported on line 7a of the Form 55002022-06-0148
Number of retired or separated participants receiving benefits2022-06-010
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-0148
2021: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-0154
Total number of active participants reported on line 7a of the Form 55002021-06-0149
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-0149
2020: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-0154
Total number of active participants reported on line 7a of the Form 55002020-06-0153
Number of retired or separated participants receiving benefits2020-06-011
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-0154
2019: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-0166
Total number of active participants reported on line 7a of the Form 55002019-06-011
Number of retired or separated participants receiving benefits2019-06-0153
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-0154
2018: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-0163
Total number of active participants reported on line 7a of the Form 55002018-06-0164
Number of retired or separated participants receiving benefits2018-06-012
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-0166
2017: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-0161
Total number of active participants reported on line 7a of the Form 55002017-06-0163
Number of retired or separated participants receiving benefits2017-06-010
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-0163
2016: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-0153
Total number of active participants reported on line 7a of the Form 55002016-06-0161
Number of retired or separated participants receiving benefits2016-06-010
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-0161
2015: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-0148
Total number of active participants reported on line 7a of the Form 55002015-06-0151
Number of retired or separated participants receiving benefits2015-06-012
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-0153

Financial Data on BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN

Measure Date Value
2023 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2023 401k financial data
Total plan liabilities at end of year2023-05-31$48,636
Total plan liabilities at beginning of year2023-05-31$48,099
Total income from all sources2023-05-31$819,682
Expenses. Total of all expenses incurred2023-05-31$824,946
Benefits paid (including direct rollovers)2023-05-31$451,399
Total plan assets at end of year2023-05-31$85,550
Total plan assets at beginning of year2023-05-31$90,277
Value of fidelity bond covering the plan2023-05-31$500,000
Total contributions received or receivable from participants2023-05-31$220,654
Expenses. Other expenses not covered elsewhere2023-05-31$274,561
Contributions received from other sources (not participants or employers)2023-05-31$0
Other income received2023-05-31$657
Net income (gross income less expenses)2023-05-31$-5,264
Net plan assets at end of year (total assets less liabilities)2023-05-31$36,914
Net plan assets at beginning of year (total assets less liabilities)2023-05-31$42,178
Total contributions received or receivable from employer(s)2023-05-31$598,371
Value of corrective distributions2023-05-31$73,951
Expenses. Administrative service providers (salaries,fees and commissions)2023-05-31$25,035
2022 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2022 401k financial data
Total plan liabilities at end of year2022-05-31$48,099
Total plan liabilities at beginning of year2022-05-31$84,310
Total income from all sources2022-05-31$716,987
Expenses. Total of all expenses incurred2022-05-31$914,261
Benefits paid (including direct rollovers)2022-05-31$467,569
Total plan assets at end of year2022-05-31$90,277
Total plan assets at beginning of year2022-05-31$323,762
Value of fidelity bond covering the plan2022-05-31$500,000
Total contributions received or receivable from participants2022-05-31$136,750
Expenses. Other expenses not covered elsewhere2022-05-31$235,471
Other income received2022-05-31$112
Net income (gross income less expenses)2022-05-31$-197,274
Net plan assets at end of year (total assets less liabilities)2022-05-31$42,178
Net plan assets at beginning of year (total assets less liabilities)2022-05-31$239,452
Total contributions received or receivable from employer(s)2022-05-31$580,125
Value of corrective distributions2022-05-31$188,887
Expenses. Administrative service providers (salaries,fees and commissions)2022-05-31$22,334
2021 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2021 401k financial data
Total plan liabilities at end of year2021-05-31$84,310
Total plan liabilities at beginning of year2021-05-31$31,999
Total income from all sources2021-05-31$647,283
Expenses. Total of all expenses incurred2021-05-31$764,532
Benefits paid (including direct rollovers)2021-05-31$483,960
Total plan assets at end of year2021-05-31$323,762
Total plan assets at beginning of year2021-05-31$388,700
Value of fidelity bond covering the plan2021-05-31$500,000
Total contributions received or receivable from participants2021-05-31$136,501
Expenses. Other expenses not covered elsewhere2021-05-31$220,973
Other income received2021-05-31$250
Net income (gross income less expenses)2021-05-31$-117,249
Net plan assets at end of year (total assets less liabilities)2021-05-31$239,452
Net plan assets at beginning of year (total assets less liabilities)2021-05-31$356,701
Total contributions received or receivable from employer(s)2021-05-31$510,532
Expenses. Administrative service providers (salaries,fees and commissions)2021-05-31$59,599
2020 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2020 401k financial data
Total plan liabilities at end of year2020-05-31$31,999
Total plan liabilities at beginning of year2020-05-31$15,173
Total income from all sources2020-05-31$842,843
Expenses. Total of all expenses incurred2020-05-31$542,605
Benefits paid (including direct rollovers)2020-05-31$253,100
Total plan assets at end of year2020-05-31$388,700
Total plan assets at beginning of year2020-05-31$71,636
Value of fidelity bond covering the plan2020-05-31$500,000
Total contributions received or receivable from participants2020-05-31$224,976
Expenses. Other expenses not covered elsewhere2020-05-31$226,666
Other income received2020-05-31$852
Net income (gross income less expenses)2020-05-31$300,238
Net plan assets at end of year (total assets less liabilities)2020-05-31$356,701
Net plan assets at beginning of year (total assets less liabilities)2020-05-31$56,463
Total contributions received or receivable from employer(s)2020-05-31$617,015
Expenses. Administrative service providers (salaries,fees and commissions)2020-05-31$62,839
2019 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2019 401k financial data
Total plan liabilities at end of year2019-05-31$15,173
Total plan liabilities at beginning of year2019-05-31$0
Total income from all sources2019-05-31$610,176
Expenses. Total of all expenses incurred2019-05-31$693,895
Benefits paid (including direct rollovers)2019-05-31$446,939
Total plan assets at end of year2019-05-31$71,636
Total plan assets at beginning of year2019-05-31$140,182
Value of fidelity bond covering the plan2019-05-31$500,000
Total contributions received or receivable from participants2019-05-31$165,246
Expenses. Other expenses not covered elsewhere2019-05-31$190,444
Other income received2019-05-31$192
Net income (gross income less expenses)2019-05-31$-83,719
Net plan assets at end of year (total assets less liabilities)2019-05-31$56,463
Net plan assets at beginning of year (total assets less liabilities)2019-05-31$140,182
Total contributions received or receivable from employer(s)2019-05-31$444,738
Expenses. Administrative service providers (salaries,fees and commissions)2019-05-31$56,512
2018 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2018 401k financial data
Total plan liabilities at end of year2018-05-31$0
Total plan liabilities at beginning of year2018-05-31$50,321
Total income from all sources2018-05-31$571,199
Expenses. Total of all expenses incurred2018-05-31$727,196
Benefits paid (including direct rollovers)2018-05-31$502,391
Total plan assets at end of year2018-05-31$140,182
Total plan assets at beginning of year2018-05-31$346,500
Value of fidelity bond covering the plan2018-05-31$500,000
Total contributions received or receivable from participants2018-05-31$146,650
Expenses. Other expenses not covered elsewhere2018-05-31$169,826
Other income received2018-05-31$515
Net income (gross income less expenses)2018-05-31$-155,997
Net plan assets at end of year (total assets less liabilities)2018-05-31$140,182
Net plan assets at beginning of year (total assets less liabilities)2018-05-31$296,179
Total contributions received or receivable from employer(s)2018-05-31$424,034
Expenses. Administrative service providers (salaries,fees and commissions)2018-05-31$54,979
2017 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2017 401k financial data
Total plan liabilities at end of year2017-05-31$50,321
Total plan liabilities at beginning of year2017-05-31$3,289
Total income from all sources2017-05-31$596,069
Expenses. Total of all expenses incurred2017-05-31$383,191
Benefits paid (including direct rollovers)2017-05-31$200,572
Total plan assets at end of year2017-05-31$346,500
Total plan assets at beginning of year2017-05-31$86,590
Value of fidelity bond covering the plan2017-05-31$1,000,000
Total contributions received or receivable from participants2017-05-31$128,173
Expenses. Other expenses not covered elsewhere2017-05-31$130,169
Other income received2017-05-31$348
Net income (gross income less expenses)2017-05-31$212,878
Net plan assets at end of year (total assets less liabilities)2017-05-31$296,179
Net plan assets at beginning of year (total assets less liabilities)2017-05-31$83,301
Total contributions received or receivable from employer(s)2017-05-31$467,548
Expenses. Administrative service providers (salaries,fees and commissions)2017-05-31$52,450
2016 : BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2016 401k financial data
Total plan liabilities at end of year2016-05-31$3,289
Total plan liabilities at beginning of year2016-05-31$0
Total income from all sources2016-05-31$518,877
Expenses. Total of all expenses incurred2016-05-31$435,576
Benefits paid (including direct rollovers)2016-05-31$282,349
Total plan assets at end of year2016-05-31$86,590
Total plan assets at beginning of year2016-05-31$0
Value of fidelity bond covering the plan2016-05-31$1,000,000
Total contributions received or receivable from participants2016-05-31$113,544
Expenses. Other expenses not covered elsewhere2016-05-31$104,385
Other income received2016-05-31$100
Net income (gross income less expenses)2016-05-31$83,301
Net plan assets at end of year (total assets less liabilities)2016-05-31$83,301
Net plan assets at beginning of year (total assets less liabilities)2016-05-31$0
Total contributions received or receivable from employer(s)2016-05-31$405,233
Expenses. Administrative service providers (salaries,fees and commissions)2016-05-31$48,842

Form 5500 Responses for BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN

2022: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Submission has been amendedNo
2022-06-01This submission is the final filingNo
2022-06-01This return/report is a short plan year return/report (less than 12 months)No
2022-06-01Plan is a collectively bargained planNo
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan funding arrangement – TrustYes
2022-06-01Plan benefit arrangement – InsuranceYes
2022-06-01Plan benefit arrangement - TrustYes
2021: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Submission has been amendedNo
2021-06-01This submission is the final filingNo
2021-06-01This return/report is a short plan year return/report (less than 12 months)No
2021-06-01Plan is a collectively bargained planNo
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan funding arrangement – TrustYes
2021-06-01Plan benefit arrangement – InsuranceYes
2021-06-01Plan benefit arrangement - TrustYes
2020: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Submission has been amendedNo
2020-06-01This submission is the final filingNo
2020-06-01This return/report is a short plan year return/report (less than 12 months)No
2020-06-01Plan is a collectively bargained planNo
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan funding arrangement – TrustYes
2020-06-01Plan benefit arrangement – InsuranceYes
2020-06-01Plan benefit arrangement - TrustYes
2019: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedNo
2019-06-01This submission is the final filingNo
2019-06-01This return/report is a short plan year return/report (less than 12 months)No
2019-06-01Plan is a collectively bargained planNo
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan funding arrangement – TrustYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement - TrustYes
2018: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – TrustYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement - TrustYes
2017: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – TrustYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement - TrustYes
2016: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – TrustYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement - TrustYes
2015: BREWERY PRODUCTS COMPANY GROUP INSURANCE PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01First time form 5500 has been submittedYes
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – TrustYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number30800012
Policy instance 4
Insurance contract or identification number30800012
Number of Individuals Covered48
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $243,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered62
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,937
Total amount of fees paid to insurance companyUSD $138
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,937
Amount paid for insurance broker fees138
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered56
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $273
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $273
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number221041
Policy instance 1
Insurance contract or identification number221041
Number of Individuals Covered0
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number221041
Policy instance 1
Insurance contract or identification number221041
Number of Individuals Covered0
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered48
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $210
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $210
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered56
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $2,739
Total amount of fees paid to insurance companyUSD $309
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,739
Amount paid for insurance broker fees309
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number30800012
Policy instance 4
Insurance contract or identification number30800012
Number of Individuals Covered49
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $206,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 5
Insurance contract or identification number670579
Number of Individuals Covered0
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D & STD
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 5
Insurance contract or identification number670579
Number of Individuals Covered0
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D & STD
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number30800012
Policy instance 4
Insurance contract or identification number30800012
Number of Individuals Covered53
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $220,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered0
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered50
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $333
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $333
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number221041
Policy instance 1
Insurance contract or identification number221041
Number of Individuals Covered51
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 5
Insurance contract or identification number670579
Number of Individuals Covered0
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D & STD
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberGENESIS
Policy instance 4
Insurance contract or identification numberGENESIS
Number of Individuals Covered53
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $226,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered62
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,410
Total amount of fees paid to insurance companyUSD $314
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,410
Amount paid for insurance broker fees314
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered59
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $223
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $223
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90987260
Policy instance 1
Insurance contract or identification number90987260
Number of Individuals Covered60
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,501
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,501
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90987260
Policy instance 1
Insurance contract or identification number90987260
Number of Individuals Covered62
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,413
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,413
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered59
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $366
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $366
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered57
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,886
Total amount of fees paid to insurance companyUSD $236
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,886
Amount paid for insurance broker fees236
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberGENESIS
Policy instance 4
Insurance contract or identification numberGENESIS
Number of Individuals Covered64
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $190,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 5
Insurance contract or identification number670579
Number of Individuals Covered2
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $60
Total amount of fees paid to insurance companyUSD $8
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D & STD
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 $600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $60
Amount paid for insurance broker fees8
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberGENESIS
Policy instance 4
Insurance contract or identification numberGENESIS
Number of Individuals Covered57
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $169,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number670579
Policy instance 3
Insurance contract or identification number670579
Number of Individuals Covered63
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,989
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,989
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
Insurance broker nameGUNN MOWERY LLC
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1530
Policy instance 2
Insurance contract or identification number1530
Number of Individuals Covered60
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $250
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $250
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
Insurance broker nameGUNN MOWERY LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90987260
Policy instance 1
Insurance contract or identification number90987260
Number of Individuals Covered61
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,629
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,629
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
Insurance broker nameGUNN MOWERY LLC

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