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TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 401k Plan overview

Plan NameTRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN
Plan identification number 502

TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)

401k Sponsoring company profile

TRI-BORO CONSTRUCTION SUPPLIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:TRI-BORO CONSTRUCTION SUPPLIES, INC.
Employer identification number (EIN):231919676
NAIC Classification:423300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022023-02-01
5022022-02-01
5022021-02-01
5022020-02-01
5022019-02-01
5022018-02-01
5022017-02-01LINDA REXROTH
5022016-02-01LINDA REXROTH
5022015-02-01LINDA REXROTH
5022014-02-01SCOTT WILT

Plan Statistics for TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN

401k plan membership statisitcs for TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN

Measure Date Value
2023: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2023 401k membership
Total participants, beginning-of-year2023-02-0150
Total number of active participants reported on line 7a of the Form 55002023-02-0116
Number of retired or separated participants receiving benefits2023-02-010
Number of other retired or separated participants entitled to future benefits2023-02-010
Total of all active and inactive participants2023-02-0116
2022: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-0150
Total number of active participants reported on line 7a of the Form 55002022-02-0150
Number of retired or separated participants receiving benefits2022-02-010
Number of other retired or separated participants entitled to future benefits2022-02-010
Total of all active and inactive participants2022-02-0150
2021: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-0158
Total number of active participants reported on line 7a of the Form 55002021-02-0150
Number of retired or separated participants receiving benefits2021-02-010
Number of other retired or separated participants entitled to future benefits2021-02-010
Total of all active and inactive participants2021-02-0150
2020: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-0166
Total number of active participants reported on line 7a of the Form 55002020-02-0158
Number of retired or separated participants receiving benefits2020-02-010
Number of other retired or separated participants entitled to future benefits2020-02-010
Total of all active and inactive participants2020-02-0158
2019: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-02-0158
Total number of active participants reported on line 7a of the Form 55002019-02-0166
Number of retired or separated participants receiving benefits2019-02-010
Number of other retired or separated participants entitled to future benefits2019-02-010
Total of all active and inactive participants2019-02-0166
2018: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-02-0157
Total number of active participants reported on line 7a of the Form 55002018-02-0158
Number of retired or separated participants receiving benefits2018-02-010
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-0158
2017: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-02-0155
Total number of active participants reported on line 7a of the Form 55002017-02-0157
Number of retired or separated participants receiving benefits2017-02-010
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-0157
2016: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-0155
Total number of active participants reported on line 7a of the Form 55002016-02-0154
Number of retired or separated participants receiving benefits2016-02-011
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-0155
2015: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-02-0154
Total number of active participants reported on line 7a of the Form 55002015-02-0154
Number of retired or separated participants receiving benefits2015-02-011
Number of other retired or separated participants entitled to future benefits2015-02-010
Total of all active and inactive participants2015-02-0155
2014: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-02-0154
Total number of active participants reported on line 7a of the Form 55002014-02-0154
Number of retired or separated participants receiving benefits2014-02-010
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-0154

Financial Data on TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN

Measure Date Value
2024 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2024 401k financial data
Total plan liabilities at end of year2024-01-31$10,132
Total plan liabilities at beginning of year2024-01-31$48,424
Total income from all sources2024-01-31$347,868
Expenses. Total of all expenses incurred2024-01-31$412,043
Benefits paid (including direct rollovers)2024-01-31$192,123
Total plan assets at end of year2024-01-31$6,978
Total plan assets at beginning of year2024-01-31$109,445
Value of fidelity bond covering the plan2024-01-31$250,000
Total contributions received or receivable from participants2024-01-31$122,849
Expenses. Other expenses not covered elsewhere2024-01-31$167,684
Contributions received from other sources (not participants or employers)2024-01-31$0
Other income received2024-01-31$619
Net income (gross income less expenses)2024-01-31$-64,175
Net plan assets at end of year (total assets less liabilities)2024-01-31$-3,154
Net plan assets at beginning of year (total assets less liabilities)2024-01-31$61,021
Total contributions received or receivable from employer(s)2024-01-31$224,400
Value of corrective distributions2024-01-31$46,553
Expenses. Administrative service providers (salaries,fees and commissions)2024-01-31$5,683
2023 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2023 401k financial data
Total plan liabilities at end of year2023-01-31$48,424
Total plan liabilities at beginning of year2023-01-31$27,195
Total income from all sources2023-01-31$501,628
Expenses. Total of all expenses incurred2023-01-31$633,510
Benefits paid (including direct rollovers)2023-01-31$321,777
Total plan assets at end of year2023-01-31$109,445
Total plan assets at beginning of year2023-01-31$220,098
Value of fidelity bond covering the plan2023-01-31$250,000
Total contributions received or receivable from participants2023-01-31$191,075
Expenses. Other expenses not covered elsewhere2023-01-31$241,473
Other income received2023-01-31$380
Net income (gross income less expenses)2023-01-31$-131,882
Net plan assets at end of year (total assets less liabilities)2023-01-31$61,021
Net plan assets at beginning of year (total assets less liabilities)2023-01-31$192,903
Total contributions received or receivable from employer(s)2023-01-31$310,173
Value of corrective distributions2023-01-31$60,000
Expenses. Administrative service providers (salaries,fees and commissions)2023-01-31$10,260
2022 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2022 401k financial data
Total plan liabilities at end of year2022-01-31$27,195
Total plan liabilities at beginning of year2022-01-31$17,127
Total income from all sources2022-01-31$567,231
Expenses. Total of all expenses incurred2022-01-31$747,263
Benefits paid (including direct rollovers)2022-01-31$350,443
Total plan assets at end of year2022-01-31$220,098
Total plan assets at beginning of year2022-01-31$390,062
Value of fidelity bond covering the plan2022-01-31$250,000
Total contributions received or receivable from participants2022-01-31$210,863
Expenses. Other expenses not covered elsewhere2022-01-31$261,109
Other income received2022-01-31$838
Net income (gross income less expenses)2022-01-31$-180,032
Net plan assets at end of year (total assets less liabilities)2022-01-31$192,903
Net plan assets at beginning of year (total assets less liabilities)2022-01-31$372,935
Total contributions received or receivable from employer(s)2022-01-31$355,530
Value of corrective distributions2022-01-31$120,000
Expenses. Administrative service providers (salaries,fees and commissions)2022-01-31$15,711
2021 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2021 401k financial data
Total plan liabilities at end of year2021-01-31$17,127
Total plan liabilities at beginning of year2021-01-31$38,671
Total income from all sources2021-01-31$626,454
Expenses. Total of all expenses incurred2021-01-31$549,000
Benefits paid (including direct rollovers)2021-01-31$197,674
Total plan assets at end of year2021-01-31$390,062
Total plan assets at beginning of year2021-01-31$334,152
Value of fidelity bond covering the plan2021-01-31$250,000
Total contributions received or receivable from participants2021-01-31$235,430
Expenses. Other expenses not covered elsewhere2021-01-31$272,307
Contributions received from other sources (not participants or employers)2021-01-31$0
Other income received2021-01-31$1,063
Net income (gross income less expenses)2021-01-31$77,454
Net plan assets at end of year (total assets less liabilities)2021-01-31$372,935
Net plan assets at beginning of year (total assets less liabilities)2021-01-31$295,481
Total contributions received or receivable from employer(s)2021-01-31$389,961
Value of corrective distributions2021-01-31$60,000
Expenses. Administrative service providers (salaries,fees and commissions)2021-01-31$19,019
2020 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2020 401k financial data
Total plan liabilities at end of year2020-01-31$38,671
Total plan liabilities at beginning of year2020-01-31$22,858
Total income from all sources2020-01-31$632,219
Expenses. Total of all expenses incurred2020-01-31$593,366
Benefits paid (including direct rollovers)2020-01-31$255,805
Total plan assets at end of year2020-01-31$334,152
Total plan assets at beginning of year2020-01-31$279,486
Value of fidelity bond covering the plan2020-01-31$250,000
Total contributions received or receivable from participants2020-01-31$225,451
Expenses. Other expenses not covered elsewhere2020-01-31$244,936
Contributions received from other sources (not participants or employers)2020-01-31$0
Other income received2020-01-31$688
Net income (gross income less expenses)2020-01-31$38,853
Net plan assets at end of year (total assets less liabilities)2020-01-31$295,481
Net plan assets at beginning of year (total assets less liabilities)2020-01-31$256,628
Total contributions received or receivable from employer(s)2020-01-31$406,080
Value of corrective distributions2020-01-31$60,000
Expenses. Administrative service providers (salaries,fees and commissions)2020-01-31$32,625
2019 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2019 401k financial data
Total plan liabilities at end of year2019-01-31$22,858
Total plan liabilities at beginning of year2019-01-31$32,615
Total income from all sources2019-01-31$592,222
Expenses. Total of all expenses incurred2019-01-31$671,968
Benefits paid (including direct rollovers)2019-01-31$203,355
Total plan assets at end of year2019-01-31$279,486
Total plan assets at beginning of year2019-01-31$368,989
Value of fidelity bond covering the plan2019-01-31$250,000
Total contributions received or receivable from participants2019-01-31$204,777
Expenses. Other expenses not covered elsewhere2019-01-31$233,418
Other income received2019-01-31$756
Net income (gross income less expenses)2019-01-31$-79,746
Net plan assets at end of year (total assets less liabilities)2019-01-31$256,628
Net plan assets at beginning of year (total assets less liabilities)2019-01-31$336,374
Total contributions received or receivable from employer(s)2019-01-31$386,689
Value of corrective distributions2019-01-31$207,280
Expenses. Administrative service providers (salaries,fees and commissions)2019-01-31$27,915
2018 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2018 401k financial data
Total plan liabilities at end of year2018-01-31$32,615
Total plan liabilities at beginning of year2018-01-31$30,680
Total income from all sources2018-01-31$622,232
Expenses. Total of all expenses incurred2018-01-31$605,305
Benefits paid (including direct rollovers)2018-01-31$175,394
Total plan assets at end of year2018-01-31$368,989
Total plan assets at beginning of year2018-01-31$350,127
Value of fidelity bond covering the plan2018-01-31$250,000
Total contributions received or receivable from participants2018-01-31$202,381
Expenses. Other expenses not covered elsewhere2018-01-31$208,609
Contributions received from other sources (not participants or employers)2018-01-31$10,488
Other income received2018-01-31$816
Net income (gross income less expenses)2018-01-31$16,927
Net plan assets at end of year (total assets less liabilities)2018-01-31$336,374
Net plan assets at beginning of year (total assets less liabilities)2018-01-31$319,447
Total contributions received or receivable from employer(s)2018-01-31$408,547
Value of corrective distributions2018-01-31$186,609
Expenses. Administrative service providers (salaries,fees and commissions)2018-01-31$34,693
2017 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2017 401k financial data
Total plan liabilities at end of year2017-01-31$30,680
Total plan liabilities at beginning of year2017-01-31$43,889
Total income from all sources2017-01-31$619,137
Expenses. Total of all expenses incurred2017-01-31$382,700
Benefits paid (including direct rollovers)2017-01-31$151,915
Total plan assets at end of year2017-01-31$350,127
Total plan assets at beginning of year2017-01-31$126,899
Value of fidelity bond covering the plan2017-01-31$250,000
Total contributions received or receivable from participants2017-01-31$234,693
Expenses. Other expenses not covered elsewhere2017-01-31$173,137
Contributions received from other sources (not participants or employers)2017-01-31$0
Other income received2017-01-31$521
Net income (gross income less expenses)2017-01-31$236,437
Net plan assets at end of year (total assets less liabilities)2017-01-31$319,447
Net plan assets at beginning of year (total assets less liabilities)2017-01-31$83,010
Total contributions received or receivable from employer(s)2017-01-31$383,923
Value of corrective distributions2017-01-31$24,097
Expenses. Administrative service providers (salaries,fees and commissions)2017-01-31$33,551
2016 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2016 401k financial data
Total plan liabilities at end of year2016-01-31$43,889
Total plan liabilities at beginning of year2016-01-31$34,511
Total income from all sources2016-01-31$504,470
Expenses. Total of all expenses incurred2016-01-31$391,477
Benefits paid (including direct rollovers)2016-01-31$207,702
Total plan assets at end of year2016-01-31$126,899
Total plan assets at beginning of year2016-01-31$4,528
Value of fidelity bond covering the plan2016-01-31$500,000
Total contributions received or receivable from participants2016-01-31$228,899
Expenses. Other expenses not covered elsewhere2016-01-31$152,094
Other income received2016-01-31$80
Net income (gross income less expenses)2016-01-31$112,993
Net plan assets at end of year (total assets less liabilities)2016-01-31$83,010
Net plan assets at beginning of year (total assets less liabilities)2016-01-31$-29,983
Total contributions received or receivable from employer(s)2016-01-31$275,491
Expenses. Administrative service providers (salaries,fees and commissions)2016-01-31$31,681
2015 : TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2015 401k financial data
Total plan liabilities at end of year2015-01-31$34,511
Total plan liabilities at beginning of year2015-01-31$0
Total income from all sources2015-01-31$458,587
Expenses. Total of all expenses incurred2015-01-31$488,570
Benefits paid (including direct rollovers)2015-01-31$314,148
Total plan assets at end of year2015-01-31$4,528
Total plan assets at beginning of year2015-01-31$0
Value of fidelity bond covering the plan2015-01-31$500,000
Total contributions received or receivable from participants2015-01-31$253,639
Other income received2015-01-31$16
Net income (gross income less expenses)2015-01-31$-29,983
Net plan assets at end of year (total assets less liabilities)2015-01-31$-29,983
Net plan assets at beginning of year (total assets less liabilities)2015-01-31$0
Total contributions received or receivable from employer(s)2015-01-31$204,932
Expenses. Administrative service providers (salaries,fees and commissions)2015-01-31$174,422

Form 5500 Responses for TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN

2023: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2023 form 5500 responses
2023-02-01Type of plan entitySingle employer plan
2023-02-01Submission has been amendedNo
2023-02-01This submission is the final filingNo
2023-02-01This return/report is a short plan year return/report (less than 12 months)No
2023-02-01Plan is a collectively bargained planNo
2023-02-01Plan funding arrangement – InsuranceYes
2023-02-01Plan funding arrangement – TrustYes
2023-02-01Plan benefit arrangement – InsuranceYes
2023-02-01Plan benefit arrangement - TrustYes
2022: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan funding arrangement – TrustYes
2022-02-01Plan benefit arrangement – InsuranceYes
2022-02-01Plan benefit arrangement - TrustYes
2021: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Submission has been amendedNo
2021-02-01This submission is the final filingNo
2021-02-01This return/report is a short plan year return/report (less than 12 months)No
2021-02-01Plan is a collectively bargained planNo
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan funding arrangement – TrustYes
2021-02-01Plan benefit arrangement – InsuranceYes
2021-02-01Plan benefit arrangement - TrustYes
2020: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedNo
2020-02-01This submission is the final filingNo
2020-02-01This return/report is a short plan year return/report (less than 12 months)No
2020-02-01Plan is a collectively bargained planNo
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan funding arrangement – TrustYes
2020-02-01Plan benefit arrangement – InsuranceYes
2020-02-01Plan benefit arrangement - TrustYes
2019: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2019 form 5500 responses
2019-02-01Type of plan entitySingle employer plan
2019-02-01Submission has been amendedNo
2019-02-01This submission is the final filingNo
2019-02-01This return/report is a short plan year return/report (less than 12 months)No
2019-02-01Plan is a collectively bargained planNo
2019-02-01Plan funding arrangement – InsuranceYes
2019-02-01Plan funding arrangement – TrustYes
2019-02-01Plan benefit arrangement – InsuranceYes
2019-02-01Plan benefit arrangement - TrustYes
2018: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2018 form 5500 responses
2018-02-01Type of plan entitySingle employer plan
2018-02-01Submission has been amendedNo
2018-02-01This submission is the final filingNo
2018-02-01This return/report is a short plan year return/report (less than 12 months)No
2018-02-01Plan is a collectively bargained planNo
2018-02-01Plan funding arrangement – InsuranceYes
2018-02-01Plan funding arrangement – TrustYes
2018-02-01Plan benefit arrangement – InsuranceYes
2018-02-01Plan benefit arrangement - TrustYes
2017: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Submission has been amendedNo
2017-02-01This submission is the final filingNo
2017-02-01This return/report is a short plan year return/report (less than 12 months)No
2017-02-01Plan is a collectively bargained planNo
2017-02-01Plan funding arrangement – InsuranceYes
2017-02-01Plan funding arrangement – TrustYes
2017-02-01Plan benefit arrangement – InsuranceYes
2017-02-01Plan benefit arrangement - TrustYes
2016: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan funding arrangement – TrustYes
2016-02-01Plan benefit arrangement – InsuranceYes
2016-02-01Plan benefit arrangement - TrustYes
2015: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan funding arrangement – TrustYes
2015-02-01Plan benefit arrangement – InsuranceYes
2015-02-01Plan benefit arrangement - TrustYes
2014: TRI-BORO CONSTRUCTION SUPPLIES, INC. GROUP MEDICAL PLAN 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01First time form 5500 has been submittedYes
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – TrustYes
2014-02-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number409117-A
Policy instance 2
Insurance contract or identification number409117-A
Number of Individuals Covered16
Insurance policy start date2024-01-01
Insurance policy end date2024-01-31
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 $7,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract number30500096
Policy instance 1
Insurance contract or identification number30500096
Number of Individuals Covered16
Insurance policy start date2023-02-01
Insurance policy end date2023-12-31
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 $142,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract number30500096
Policy instance 1
Insurance contract or identification number30500096
Number of Individuals Covered50
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
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 $212,440
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract number30500096
Policy instance 1
Insurance contract or identification number30500096
Number of Individuals Covered50
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
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 $225,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract number30500096
Policy instance 1
Insurance contract or identification number30500096
Number of Individuals Covered58
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
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 $236,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered66
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
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 $228,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered58
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
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 $181,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered57
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
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 $173,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberVERIS
Policy instance 2
Insurance contract or identification numberVERIS
Number of Individuals Covered0
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $-250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered55
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $122,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberVERIS
Policy instance 2
Insurance contract or identification numberVERIS
Number of Individuals Covered54
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $100,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 26921 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered54
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $10,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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