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DOLLAR BANK WELFARE BENEFITS PLAN 401k Plan overview

Plan NameDOLLAR BANK WELFARE BENEFITS PLAN
Plan identification number 501

DOLLAR BANK WELFARE BENEFITS PLAN 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
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DOLLAR BANK, FEDERAL SAVINGS BANK has sponsored the creation of one or more 401k plans.

Company Name:DOLLAR BANK, FEDERAL SAVINGS BANK
Employer identification number (EIN):250444380
NAIC Classification:522120
NAIC Description:Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DOLLAR BANK WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01THOMAS M DOBROSIELSKI THOMAS M DOBROSIELSKI2018-10-02
5012016-01-01THOMAS M DOBROSIELSKI THOMAS M DOBROSIELSKI2017-09-18
5012015-01-01THOMAS M DOBROSIELSKI THOMAS M DOBROSIELSKI2016-10-07
5012014-01-01JAMES T JURCIC JAMES T JURCIC2015-10-14
5012014-01-01JAMES T JURCIC JAMES T JURCIC2016-01-14
5012013-01-01JAMES T JURCIC JAMES T JURCIC2014-10-06
5012012-01-01JAMES T JURCIC JAMES T JURCIC2013-10-04
5012011-01-01JAMES T JURCIC JAMES T JURCIC2012-10-02
5012009-01-01JAMES T. JURCIC JAMES T. JURCIC2010-09-30
5012009-01-01JAMES T. JURCIC JAMES T. JURCIC2010-09-30
5012009-01-01JAMES T. JURCIC JAMES T. JURCIC2010-09-30
5012009-01-01JAMES T. JURCIC JAMES T. JURCIC2010-09-30

Plan Statistics for DOLLAR BANK WELFARE BENEFITS PLAN

401k plan membership statisitcs for DOLLAR BANK WELFARE BENEFITS PLAN

Measure Date Value
2022: DOLLAR BANK WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-011,303
Total number of active participants reported on line 7a of the Form 55002022-01-011,418
Total of all active and inactive participants2022-01-011,418
2021: DOLLAR BANK WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-011,369
Total number of active participants reported on line 7a of the Form 55002021-01-011,303
Total of all active and inactive participants2021-01-011,303
2020: DOLLAR BANK WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-011,331
Total number of active participants reported on line 7a of the Form 55002020-01-011,369
Total of all active and inactive participants2020-01-011,369
2019: DOLLAR BANK WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-011,331
Total number of active participants reported on line 7a of the Form 55002019-01-011,331
Total of all active and inactive participants2019-01-011,331
2018: DOLLAR BANK WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-011,363
Total number of active participants reported on line 7a of the Form 55002018-01-011,331
Total of all active and inactive participants2018-01-011,331
2017: DOLLAR BANK WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-011,314
Total number of active participants reported on line 7a of the Form 55002017-01-011,363
Total of all active and inactive participants2017-01-011,363
2016: DOLLAR BANK WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-011,282
Total number of active participants reported on line 7a of the Form 55002016-01-011,314
Total of all active and inactive participants2016-01-011,314
2015: DOLLAR BANK WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-011,288
Total number of active participants reported on line 7a of the Form 55002015-01-011,282
Total of all active and inactive participants2015-01-011,282
2014: DOLLAR BANK WELFARE BENEFITS PLAN 2014 401k membership
Total number of active participants reported on line 7a of the Form 55002014-01-011,288
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-011,288
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-01-010
Total participants2014-01-011,288
Total participants, beginning-of-year2014-01-011,240
2013: DOLLAR BANK WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-011,231
Total number of active participants reported on line 7a of the Form 55002013-01-011,240
Total of all active and inactive participants2013-01-011,240
Total participants2013-01-011,240
2012: DOLLAR BANK WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-011,218
Total number of active participants reported on line 7a of the Form 55002012-01-011,231
Total of all active and inactive participants2012-01-011,231
Total participants2012-01-011,231
2011: DOLLAR BANK WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-011,179
Total number of active participants reported on line 7a of the Form 55002011-01-011,218
Total of all active and inactive participants2011-01-011,218
Total participants2011-01-011,218
2009: DOLLAR BANK WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-011,148
Total number of active participants reported on line 7a of the Form 55002009-01-011,169
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-011,169

Financial Data on DOLLAR BANK WELFARE BENEFITS PLAN

Measure Date Value
2014 : DOLLAR BANK WELFARE BENEFITS PLAN 2014 401k financial data
Total income from all sources (including contributions)2014-12-31$10,904,900
Total of all expenses incurred2014-12-31$10,904,900
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2014-12-31$10,122,864
Total contributions o plan (from employers,participants, others, non cash contrinutions)2014-12-31$10,904,900
Total of administrative expenses incurred including professional, contract, advisory and management fees2014-12-31$782,036
Contributions received from participants2014-12-31$3,036,262
Value of net income/loss2014-12-31$0
Investment advisory and management fees2014-12-31$768,256
Expenses. Payments to insurance carriers foe the provision of benefits2014-12-31$1,596,407
Contributions received in cash from employer2014-12-31$7,868,638
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2014-12-31$8,526,457
Contract administrator fees2014-12-31$13,780
2013 : DOLLAR BANK WELFARE BENEFITS PLAN 2013 401k financial data
Total income from all sources (including contributions)2013-12-31$211,588
Total of all expenses incurred2013-12-31$211,588
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-12-31$211,588
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-12-31$211,588
Value of net income/loss2013-12-31$0
Expenses. Payments to insurance carriers foe the provision of benefits2013-12-31$211,588
Contributions received in cash from employer2013-12-31$211,588
2012 : DOLLAR BANK WELFARE BENEFITS PLAN 2012 401k financial data
Total income from all sources (including contributions)2012-12-31$201,430
Total of all expenses incurred2012-12-31$201,430
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2012-12-31$201,430
Total contributions o plan (from employers,participants, others, non cash contrinutions)2012-12-31$201,430
Value of net income/loss2012-12-31$0
Expenses. Payments to insurance carriers foe the provision of benefits2012-12-31$201,430
Contributions received in cash from employer2012-12-31$201,430
2011 : DOLLAR BANK WELFARE BENEFITS PLAN 2011 401k financial data
Total income from all sources (including contributions)2011-12-31$193,156
Total of all expenses incurred2011-12-31$193,156
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2011-12-31$193,156
Total contributions o plan (from employers,participants, others, non cash contrinutions)2011-12-31$193,156
Value of net income/loss2011-12-31$0
Expenses. Payments to insurance carriers foe the provision of benefits2011-12-31$193,156
Contributions received in cash from employer2011-12-31$193,156
2010 : DOLLAR BANK WELFARE BENEFITS PLAN 2010 401k financial data
Total income from all sources (including contributions)2010-12-31$187,967
Total of all expenses incurred2010-12-31$187,967
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2010-12-31$187,789
Total contributions o plan (from employers,participants, others, non cash contrinutions)2010-12-31$187,967
Total of administrative expenses incurred including professional, contract, advisory and management fees2010-12-31$178
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2010-12-31No
Was this plan covered by a fidelity bond2010-12-31No
If this is an individual account plan, was there a blackout period2010-12-31No
Were there any nonexempt tranactions with any party-in-interest2010-12-31No
Income. Received or receivable in cash from other sources (including rollovers)2010-12-31$187,967
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2010-12-31No
Value of net income/loss2010-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2010-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2010-12-31No
Were any leases to which the plan was party in default or uncollectible2010-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2010-12-31$187,789
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2010-12-31No
Was there a failure to transmit to the plan any participant contributions2010-12-31No
Has the plan failed to provide any benefit when due under the plan2010-12-31No
Contributions received in cash from employer2010-12-31$187,967
Contract administrator fees2010-12-31$178
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32010-12-31No
Did the plan have assets held for investment2010-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2010-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2010-12-31No

Form 5500 Responses for DOLLAR BANK WELFARE BENEFITS PLAN

2022: DOLLAR BANK WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: DOLLAR BANK WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DOLLAR BANK WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: DOLLAR BANK WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: DOLLAR BANK WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: DOLLAR BANK WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: DOLLAR BANK WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: DOLLAR BANK WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: DOLLAR BANK WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedYes
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: DOLLAR BANK WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entityDFE (Diect Filing Entity)
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: DOLLAR BANK WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01Type of plan entityDFE (Diect Filing Entity)
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: DOLLAR BANK WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01Type of plan entityDFE (Diect Filing Entity)
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: DOLLAR BANK WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1082
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $1,119,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1416
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $715,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )
Policy contract numberGTA101123
Policy instance 2
Insurance contract or identification numberGTA101123
Number of Individuals Covered1418
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $1,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1932
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $157,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1633
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $138,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )
Policy contract numberGTA101123
Policy instance 2
Insurance contract or identification numberGTA101123
Number of Individuals Covered1303
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $205
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $1,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $205
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1384
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $646,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1037
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $1,081,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1068
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $1,134,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1384
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $626,056
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 numberETB111478
Policy instance 2
Insurance contract or identification numberETB111478
Number of Individuals Covered1369
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $205
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $1,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $205
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1656
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $138,514
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 numberETB111478
Policy instance 2
Insurance contract or identification numberETB111478
Number of Individuals Covered1331
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $205
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $1,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $205
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1606
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $133,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1349
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $606,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1024
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $1,166,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1050
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $934,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1557
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $131,214
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 numberETB111478
Policy instance 2
Insurance contract or identification numberETB111478
Number of Individuals Covered1331
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $135
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $135
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1336
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $564,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number406410 0010SSLS
Policy instance 4
Insurance contract or identification number406410 0010SSLS
Number of Individuals Covered1008
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $666,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number41185
Policy instance 3
Insurance contract or identification number41185
Number of Individuals Covered1285
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $441,116
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 numberETB111478
Policy instance 2
Insurance contract or identification numberETB111478
Number of Individuals Covered1363
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $135
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL
Welfare Benefit Premiums Paid to CarrierUSD $903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $135
Insurance broker organization code?3
Insurance broker nameDOLLAR BANK INSURANCE AGENCY INC.
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberDBF/001,002,003
Policy instance 1
Insurance contract or identification numberDBF/001,002,003
Number of Individuals Covered1543
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $129,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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