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CJ'S TIRE & SERVICE, INC. 401k Plan overview

Plan NameCJ'S TIRE & SERVICE, INC.
Plan identification number 501

CJ'S TIRE & SERVICE, INC. Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

C & J TIRE SERVICE, INC. has sponsored the creation of one or more 401k plans.

Company Name:C & J TIRE SERVICE, INC.
Employer identification number (EIN):232196819
NAIC Classification:441300
NAIC Description: Automotive Parts, Accessories, and Tire Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CJ'S TIRE & SERVICE, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01MICHAEL HOUCK2023-12-13 PAUL LEVENGOOD, JR.2023-12-13
5012021-06-01MICHAEL HOUCK2022-12-07 PAUL LEVENGOOD, JR.2022-12-07
5012020-06-01MICHAEL HOUCK2021-12-14 PAUL LEVENGOOD, JR.2021-12-14
5012019-06-01MICHAEL HOUCK2020-11-30 PAUL LEVENGOOD, JR.2020-11-30
5012018-06-01MICHAEL HOUCK2019-12-09 PAUL LEVENGOOD, JR.2019-12-09
5012017-06-01
5012016-06-01
5012015-06-01
5012014-06-01
5012013-06-01
5012012-06-01MICHAEL HOUCK
5012011-06-01MICHAEL HOUCK
5012010-06-01NANCY GRYCEWICZ

Plan Statistics for CJ'S TIRE & SERVICE, INC.

401k plan membership statisitcs for CJ'S TIRE & SERVICE, INC.

Measure Date Value
2022: CJ'S TIRE & SERVICE, INC. 2022 401k membership
Total participants, beginning-of-year2022-06-01242
Total number of active participants reported on line 7a of the Form 55002022-06-01217
Total of all active and inactive participants2022-06-01217
2021: CJ'S TIRE & SERVICE, INC. 2021 401k membership
Total participants, beginning-of-year2021-06-01173
Total number of active participants reported on line 7a of the Form 55002021-06-01242
Total of all active and inactive participants2021-06-01242
2020: CJ'S TIRE & SERVICE, INC. 2020 401k membership
Total participants, beginning-of-year2020-06-01167
Total number of active participants reported on line 7a of the Form 55002020-06-01173
Total of all active and inactive participants2020-06-01173
2019: CJ'S TIRE & SERVICE, INC. 2019 401k membership
Total participants, beginning-of-year2019-06-01182
Total number of active participants reported on line 7a of the Form 55002019-06-01167
Total of all active and inactive participants2019-06-01167
2018: CJ'S TIRE & SERVICE, INC. 2018 401k membership
Total participants, beginning-of-year2018-06-01150
Total number of active participants reported on line 7a of the Form 55002018-06-01182
Total of all active and inactive participants2018-06-01182
2017: CJ'S TIRE & SERVICE, INC. 2017 401k membership
Total participants, beginning-of-year2017-06-01124
Total number of active participants reported on line 7a of the Form 55002017-06-01150
Total of all active and inactive participants2017-06-01150
2016: CJ'S TIRE & SERVICE, INC. 2016 401k membership
Total participants, beginning-of-year2016-06-01115
Total number of active participants reported on line 7a of the Form 55002016-06-01124
Total of all active and inactive participants2016-06-01124
2015: CJ'S TIRE & SERVICE, INC. 2015 401k membership
Total participants, beginning-of-year2015-06-01114
Total number of active participants reported on line 7a of the Form 55002015-06-01113
Total of all active and inactive participants2015-06-01113
2014: CJ'S TIRE & SERVICE, INC. 2014 401k membership
Total participants, beginning-of-year2014-06-01105
Total number of active participants reported on line 7a of the Form 55002014-06-01114
Total of all active and inactive participants2014-06-01114
2013: CJ'S TIRE & SERVICE, INC. 2013 401k membership
Total participants, beginning-of-year2013-06-01105
Total number of active participants reported on line 7a of the Form 55002013-06-01105
Total of all active and inactive participants2013-06-01105
2012: CJ'S TIRE & SERVICE, INC. 2012 401k membership
Total participants, beginning-of-year2012-06-01124
Total number of active participants reported on line 7a of the Form 55002012-06-01103
Number of retired or separated participants receiving benefits2012-06-011
Number of other retired or separated participants entitled to future benefits2012-06-011
Total of all active and inactive participants2012-06-01105
2011: CJ'S TIRE & SERVICE, INC. 2011 401k membership
Total participants, beginning-of-year2011-06-01118
Total number of active participants reported on line 7a of the Form 55002011-06-01122
Number of retired or separated participants receiving benefits2011-06-011
Number of other retired or separated participants entitled to future benefits2011-06-011
Total of all active and inactive participants2011-06-01124
2010: CJ'S TIRE & SERVICE, INC. 2010 401k membership
Total participants, beginning-of-year2010-06-01112
Total number of active participants reported on line 7a of the Form 55002010-06-01118
Total of all active and inactive participants2010-06-01118

Form 5500 Responses for CJ'S TIRE & SERVICE, INC.

2022: CJ'S TIRE & SERVICE, INC. 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan funding arrangement – General assets of the sponsorYes
2022-06-01Plan benefit arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – General assets of the sponsorYes
2021: CJ'S TIRE & SERVICE, INC. 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan funding arrangement – General assets of the sponsorYes
2021-06-01Plan benefit arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – General assets of the sponsorYes
2020: CJ'S TIRE & SERVICE, INC. 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan funding arrangement – General assets of the sponsorYes
2020-06-01Plan benefit arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – General assets of the sponsorYes
2019: CJ'S TIRE & SERVICE, INC. 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan funding arrangement – General assets of the sponsorYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – General assets of the sponsorYes
2018: CJ'S TIRE & SERVICE, INC. 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – General assets of the sponsorYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – General assets of the sponsorYes
2017: CJ'S TIRE & SERVICE, INC. 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2016: CJ'S TIRE & SERVICE, INC. 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – General assets of the sponsorYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – General assets of the sponsorYes
2015: CJ'S TIRE & SERVICE, INC. 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes
2014: CJ'S TIRE & SERVICE, INC. 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan funding arrangement – General assets of the sponsorYes
2014-06-01Plan benefit arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – General assets of the sponsorYes
2013: CJ'S TIRE & SERVICE, INC. 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan funding arrangement – General assets of the sponsorYes
2013-06-01Plan benefit arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – General assets of the sponsorYes
2012: CJ'S TIRE & SERVICE, INC. 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan funding arrangement – General assets of the sponsorYes
2012-06-01Plan benefit arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – General assets of the sponsorYes
2011: CJ'S TIRE & SERVICE, INC. 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan funding arrangement – General assets of the sponsorYes
2011-06-01Plan benefit arrangement – InsuranceYes
2011-06-01Plan benefit arrangement – General assets of the sponsorYes
2010: CJ'S TIRE & SERVICE, INC. 2010 form 5500 responses
2010-06-01Type of plan entitySingle employer plan
2010-06-01First time form 5500 has been submittedYes
2010-06-01Plan funding arrangement – InsuranceYes
2010-06-01Plan funding arrangement – General assets of the sponsorYes
2010-06-01Plan benefit arrangement – InsuranceYes
2010-06-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1141623
Policy instance 2
Insurance contract or identification number1141623
Number of Individuals Covered217
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $10,424
Total amount of fees paid to insurance companyUSD $504
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $65,955
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,621
Amount paid for insurance broker fees504
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0148999
Policy instance 1
Insurance contract or identification number0148999
Number of Individuals Covered165
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $14,502
Total amount of fees paid to insurance companyUSD $2,500
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,071,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,931
Insurance broker organization code?3
Amount paid for insurance broker fees2500
Additional information about fees paid to insurance broker2022 Q2 GROW WITH US NEW BUSINESS INCENTIVE RISK
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1141623
Policy instance 2
Insurance contract or identification number1141623
Number of Individuals Covered202
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $20,446
Total amount of fees paid to insurance companyUSD $5,619
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $115,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,934
Amount paid for insurance broker fees5619
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )
Policy contract number00701218
Policy instance 1
Insurance contract or identification number00701218
Number of Individuals Covered242
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $35,945
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $907,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,945
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 2
Insurance contract or identification number770339
Number of Individuals Covered67
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $883
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $883
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 1
Insurance contract or identification number770339
Number of Individuals Covered81
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,984
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,516
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 3
Insurance contract or identification number770339
Number of Individuals Covered46
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $5,369
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,201
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )
Policy contract number00701218
Policy instance 4
Insurance contract or identification number00701218
Number of Individuals Covered173
Insurance policy start date2020-06-01
Insurance policy end date2021-05-30
Total amount of commissions paid to insurance brokerUSD $40,355
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $774,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,355
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0169389
Policy instance 5
Insurance contract or identification number0169389
Number of Individuals Covered166
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $5,114
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $46,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,983
Amount paid for insurance broker fees0
Insurance broker organization code?3
MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )
Policy contract number61468-MNL
Policy instance 6
Insurance contract or identification number61468-MNL
Number of Individuals Covered169
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,501
Total amount of fees paid to insurance companyUSD $2,779
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,244
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 brokerN/A
Insurance broker organization code?3
CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 )
Policy contract number00701218
Policy instance 5
Insurance contract or identification number00701218
Number of Individuals Covered167
Insurance policy start date2019-06-01
Insurance policy end date2020-05-30
Total amount of commissions paid to insurance brokerUSD $32,900
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $816,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,900
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 4
Insurance contract or identification number770339
Number of Individuals Covered61
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,388
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,043
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 3
Insurance contract or identification number770339
Number of Individuals Covered83
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $942
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $942
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 2
Insurance contract or identification number770339
Number of Individuals Covered104
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,460
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,500
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number659201
Policy instance 1
Insurance contract or identification number659201
Number of Individuals Covered114
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,315
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,315
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 5
Insurance contract or identification number770339
Number of Individuals Covered64
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $5,273
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,033
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 4
Insurance contract or identification number770339
Number of Individuals Covered81
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $859
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $859
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number770339
Policy instance 3
Insurance contract or identification number770339
Number of Individuals Covered95
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,735
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,346
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number914653
Policy instance 2
Insurance contract or identification number914653
Number of Individuals Covered182
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $4,239
Total amount of fees paid to insurance companyUSD $45,168
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $773,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees35583
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number659201
Policy instance 1
Insurance contract or identification number659201
Number of Individuals Covered111
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $4,958
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $55,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,958
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1065301
Policy instance 1
Insurance contract or identification number1065301
Number of Individuals Covered220
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $12,542
Total amount of fees paid to insurance companyUSD $1,145
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $109,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,542
Amount paid for insurance broker fees1145
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameKISTLER TIFFANY BENEFITS COMPANY
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05910205
Policy instance 1
Insurance contract or identification numberTS05910205
Number of Individuals Covered178
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $10,238
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $98,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,754
Insurance broker organization code?3
Insurance broker nameKISTLER TIFFANY BENEFITS CO.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869448G
Policy instance 1
Insurance contract or identification number869448G
Number of Individuals Covered105
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $46
Total amount of fees paid to insurance companyUSD $11
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46
Amount paid for insurance broker fees11
Insurance broker organization code?3
Insurance broker nameKISTLER-TIFFANY BENE CO.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05910205
Policy instance 2
Insurance contract or identification numberTS05910205
Number of Individuals Covered164
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $10,665
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $99,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,458
Insurance broker organization code?3
Insurance broker nameKISTLER TIFFANY BENEFITS CO.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869448G
Policy instance 1
Insurance contract or identification number869448G
Number of Individuals Covered109
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $6,403
Total amount of fees paid to insurance companyUSD $1,507
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $37,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,403
Amount paid for insurance broker fees1507
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameKISTLER-TIFFANY BENE CO.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869448G
Policy instance 1
Insurance contract or identification number869448G
Number of Individuals Covered103
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $6,713
Total amount of fees paid to insurance companyUSD $1,585
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $39,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,713
Amount paid for insurance broker fees1585
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameKISTLER-TIFFANY BENE CO.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869448G
Policy instance 1
Insurance contract or identification number869448G
Number of Individuals Covered122
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $6,701
Total amount of fees paid to insurance companyUSD $1,531
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $39,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869448G
Policy instance 1
Insurance contract or identification number869448G
Number of Individuals Covered118
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $8,855
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $38,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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