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ELECTROMET CORPORATION WELFARE BENEFITS PLAN 401k Plan overview

Plan NameELECTROMET CORPORATION WELFARE BENEFITS PLAN
Plan identification number 501

ELECTROMET CORPORATION WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover

401k Sponsoring company profile

ELECTROMET CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:ELECTROMET CORPORATION
Employer identification number (EIN):251266054
NAIC Classification:332810

Additional information about ELECTROMET CORPORATION

Jurisdiction of Incorporation: Maryland Secretary of State
Incorporation Date:
Company Identification Number: D06373849

More information about ELECTROMET CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ELECTROMET CORPORATION WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-12-01
5012021-06-02
5012020-06-02
5012019-06-02
5012018-06-02
5012017-06-02DAVID O. MCCAIN
5012016-06-02DAVID O. MCCAIN
5012016-03-02DAVID O. MCCAIN
5012015-03-02DAVID O. MCCAIN
5012014-03-02DAVID O. MCCAIN
5012014-01-01DAVID O. MCCAIN
5012013-01-01DAVID O. MCCAIN
5012012-01-01DAVID O. MCCAIN
5012011-02-01DAVID O. MCCAIN
5012010-02-01DAVID O. MCCAIN

Plan Statistics for ELECTROMET CORPORATION WELFARE BENEFITS PLAN

401k plan membership statisitcs for ELECTROMET CORPORATION WELFARE BENEFITS PLAN

Measure Date Value
2021: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-12-01399
Total number of active participants reported on line 7a of the Form 55002021-12-01408
Number of retired or separated participants receiving benefits2021-12-010
Number of other retired or separated participants entitled to future benefits2021-12-010
Total of all active and inactive participants2021-12-01408
Total participants, beginning-of-year2021-06-02274
Total number of active participants reported on line 7a of the Form 55002021-06-02399
Number of retired or separated participants receiving benefits2021-06-020
Number of other retired or separated participants entitled to future benefits2021-06-020
Total of all active and inactive participants2021-06-02399
2020: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-02155
Total number of active participants reported on line 7a of the Form 55002020-06-02274
Number of retired or separated participants receiving benefits2020-06-020
Number of other retired or separated participants entitled to future benefits2020-06-020
Total of all active and inactive participants2020-06-02274
2019: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-02125
Total number of active participants reported on line 7a of the Form 55002019-06-02155
Number of retired or separated participants receiving benefits2019-06-020
Number of other retired or separated participants entitled to future benefits2019-06-020
Total of all active and inactive participants2019-06-02155
2018: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-02132
Total number of active participants reported on line 7a of the Form 55002018-06-02125
Number of retired or separated participants receiving benefits2018-06-020
Number of other retired or separated participants entitled to future benefits2018-06-020
Total of all active and inactive participants2018-06-02125
2017: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-02134
Total number of active participants reported on line 7a of the Form 55002017-06-02132
Number of retired or separated participants receiving benefits2017-06-020
Number of other retired or separated participants entitled to future benefits2017-06-020
Total of all active and inactive participants2017-06-02132
2016: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-02109
Total number of active participants reported on line 7a of the Form 55002016-06-02134
Number of retired or separated participants receiving benefits2016-06-020
Number of other retired or separated participants entitled to future benefits2016-06-020
Total of all active and inactive participants2016-06-02134
Total participants, beginning-of-year2016-03-02113
Total number of active participants reported on line 7a of the Form 55002016-03-02109
Number of retired or separated participants receiving benefits2016-03-020
Number of other retired or separated participants entitled to future benefits2016-03-020
Total of all active and inactive participants2016-03-02109
2015: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-02111
Total number of active participants reported on line 7a of the Form 55002015-03-02113
Number of retired or separated participants receiving benefits2015-03-020
Number of other retired or separated participants entitled to future benefits2015-03-020
Total of all active and inactive participants2015-03-02113
2014: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-0219
Total number of active participants reported on line 7a of the Form 55002014-03-02111
Number of retired or separated participants receiving benefits2014-03-020
Number of other retired or separated participants entitled to future benefits2014-03-020
Total of all active and inactive participants2014-03-02111
Total participants, beginning-of-year2014-01-01105
Total number of active participants reported on line 7a of the Form 55002014-01-0119
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 participants2014-01-0119
2013: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01118
Total number of active participants reported on line 7a of the Form 55002013-01-01105
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01105
2012: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01103
Total number of active participants reported on line 7a of the Form 55002012-01-01118
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01118
2011: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-02-01113
Total number of active participants reported on line 7a of the Form 55002011-02-01103
Number of retired or separated participants receiving benefits2011-02-010
Number of other retired or separated participants entitled to future benefits2011-02-010
Total of all active and inactive participants2011-02-01103
2010: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-02-01113
Total number of active participants reported on line 7a of the Form 55002010-02-01113
Number of retired or separated participants receiving benefits2010-02-010
Number of other retired or separated participants entitled to future benefits2010-02-010
Total of all active and inactive participants2010-02-01113

Form 5500 Responses for ELECTROMET CORPORATION WELFARE BENEFITS PLAN

2021: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-12-01Type of plan entitySingle employer plan
2021-12-01Submission has been amendedNo
2021-12-01This submission is the final filingNo
2021-12-01This return/report is a short plan year return/report (less than 12 months)No
2021-12-01Plan is a collectively bargained planNo
2021-12-01Plan funding arrangement – InsuranceYes
2021-12-01Plan benefit arrangement – InsuranceYes
2021-06-02Type of plan entitySingle employer plan
2021-06-02Submission has been amendedNo
2021-06-02This submission is the final filingNo
2021-06-02This return/report is a short plan year return/report (less than 12 months)Yes
2021-06-02Plan is a collectively bargained planNo
2021-06-02Plan funding arrangement – InsuranceYes
2021-06-02Plan benefit arrangement – InsuranceYes
2020: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-06-02Type of plan entitySingle employer plan
2020-06-02Submission has been amendedNo
2020-06-02This submission is the final filingNo
2020-06-02This return/report is a short plan year return/report (less than 12 months)No
2020-06-02Plan is a collectively bargained planNo
2020-06-02Plan funding arrangement – InsuranceYes
2020-06-02Plan benefit arrangement – InsuranceYes
2019: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-06-02Type of plan entitySingle employer plan
2019-06-02Submission has been amendedNo
2019-06-02This submission is the final filingNo
2019-06-02This return/report is a short plan year return/report (less than 12 months)No
2019-06-02Plan is a collectively bargained planNo
2019-06-02Plan funding arrangement – InsuranceYes
2019-06-02Plan benefit arrangement – InsuranceYes
2018: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-06-02Type of plan entitySingle employer plan
2018-06-02Submission has been amendedNo
2018-06-02This submission is the final filingNo
2018-06-02This return/report is a short plan year return/report (less than 12 months)No
2018-06-02Plan is a collectively bargained planNo
2018-06-02Plan funding arrangement – InsuranceYes
2018-06-02Plan benefit arrangement – InsuranceYes
2017: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-06-02Type of plan entitySingle employer plan
2017-06-02Submission has been amendedNo
2017-06-02This submission is the final filingNo
2017-06-02This return/report is a short plan year return/report (less than 12 months)No
2017-06-02Plan is a collectively bargained planNo
2017-06-02Plan funding arrangement – InsuranceYes
2017-06-02Plan benefit arrangement – InsuranceYes
2016: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-06-02Type of plan entitySingle employer plan
2016-06-02Submission has been amendedNo
2016-06-02This submission is the final filingNo
2016-06-02This return/report is a short plan year return/report (less than 12 months)No
2016-06-02Plan is a collectively bargained planNo
2016-06-02Plan funding arrangement – InsuranceYes
2016-06-02Plan benefit arrangement – InsuranceYes
2016-03-02Type of plan entitySingle employer plan
2016-03-02Submission has been amendedNo
2016-03-02This submission is the final filingNo
2016-03-02This return/report is a short plan year return/report (less than 12 months)Yes
2016-03-02Plan is a collectively bargained planNo
2016-03-02Plan funding arrangement – InsuranceYes
2016-03-02Plan benefit arrangement – InsuranceYes
2015: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-03-02Type of plan entitySingle employer plan
2015-03-02Submission has been amendedNo
2015-03-02This submission is the final filingNo
2015-03-02This return/report is a short plan year return/report (less than 12 months)No
2015-03-02Plan is a collectively bargained planNo
2015-03-02Plan funding arrangement – InsuranceYes
2015-03-02Plan benefit arrangement – InsuranceYes
2014: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-03-02Type of plan entitySingle employer plan
2014-03-02Submission has been amendedNo
2014-03-02This submission is the final filingNo
2014-03-02This return/report is a short plan year return/report (less than 12 months)No
2014-03-02Plan is a collectively bargained planNo
2014-03-02Plan funding arrangement – InsuranceYes
2014-03-02Plan benefit arrangement – InsuranceYes
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)Yes
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: ELECTROMET CORPORATION WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01First time form 5500 has been submittedYes
2010-02-01Submission has been amendedNo
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number16015181
Policy instance 4
Insurance contract or identification number16015181
Number of Individuals Covered251
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $111,258
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $701,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $85,590
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10116841001
Policy instance 3
Insurance contract or identification number10116841001
Number of Individuals Covered408
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $2,588
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,588
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-051326
Policy instance 2
Insurance contract or identification number010-051326
Number of Individuals Covered292
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $3,429
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $118,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,429
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered271
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $17,078
Total amount of fees paid to insurance companyUSD $10,059
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $296,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,078
Amount paid for insurance broker fees6340
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered206
Insurance policy start date2021-06-02
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-051326
Policy instance 2
Insurance contract or identification number010-051326
Number of Individuals Covered184
Insurance policy start date2021-06-02
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $2,363
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $57,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,363
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10116841001
Policy instance 3
Insurance contract or identification number10116841001
Number of Individuals Covered399
Insurance policy start date2021-06-02
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $1,623
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,623
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number16015181
Policy instance 4
Insurance contract or identification number16015181
Number of Individuals Covered216
Insurance policy start date2021-06-02
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $34,777
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $232,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,741
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number16015181
Policy instance 4
Insurance contract or identification number16015181
Number of Individuals Covered216
Insurance policy start date2020-06-02
Insurance policy end date2021-06-01
Total amount of commissions paid to insurance brokerUSD $34,775
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
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 $232,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,740
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10116841001
Policy instance 3
Insurance contract or identification number10116841001
Number of Individuals Covered274
Insurance policy start date2020-06-02
Insurance policy end date2021-06-01
Total amount of commissions paid to insurance brokerUSD $1,114
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,114
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-051326
Policy instance 2
Insurance contract or identification number010-051326
Number of Individuals Covered238
Insurance policy start date2020-06-02
Insurance policy end date2021-06-01
Total amount of commissions paid to insurance brokerUSD $2,924
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $78,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,924
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered206
Insurance policy start date2020-06-02
Insurance policy end date2021-06-01
Total amount of commissions paid to insurance brokerUSD $8,404
Total amount of fees paid to insurance companyUSD $4,340
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,404
Amount paid for insurance broker fees4026
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered155
Insurance policy start date2019-06-02
Insurance policy end date2020-06-01
Total amount of commissions paid to insurance brokerUSD $1,702
Total amount of fees paid to insurance companyUSD $531
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,702
Amount paid for insurance broker fees531
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered125
Insurance policy start date2018-06-02
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $1,578
Total amount of fees paid to insurance companyUSD $358
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,578
Amount paid for insurance broker fees358
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered132
Insurance policy start date2017-06-02
Insurance policy end date2018-06-01
Total amount of commissions paid to insurance brokerUSD $1,571
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,571
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered109
Insurance policy start date2016-03-02
Insurance policy end date2016-06-01
Total amount of commissions paid to insurance brokerUSD $337
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $337
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered113
Insurance policy start date2015-03-02
Insurance policy end date2016-03-01
Total amount of commissions paid to insurance brokerUSD $1,404
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,404
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AS87
Policy instance 1
Insurance contract or identification numberG000AS87
Number of Individuals Covered111
Insurance policy start date2014-03-02
Insurance policy end date2015-03-01
Total amount of commissions paid to insurance brokerUSD $1,384
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,384
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number398075
Policy instance 1
Insurance contract or identification number398075
Number of Individuals Covered19
Insurance policy start date2014-01-01
Insurance policy end date2014-03-01
Total amount of commissions paid to insurance brokerUSD $85
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $85
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. CO.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number398074
Policy instance 2
Insurance contract or identification number398074
Number of Individuals Covered105
Insurance policy start date2013-03-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,361
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,361
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER INS. CO.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number725939
Policy instance 1
Insurance contract or identification number725939
Number of Individuals Covered105
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $182
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $182
Insurance broker organization code?3
Insurance broker nameKELLER STONEBRAKER
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number725939
Policy instance 1
Insurance contract or identification number725939
Number of Individuals Covered118
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,113
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,113
Insurance broker organization code?3
Insurance broker nameJAMES SLONAKER
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number725939
Policy instance 1
Insurance contract or identification number725939
Number of Individuals Covered103
Insurance policy start date2011-02-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,020
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $25,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number725939
Policy instance 1
Insurance contract or identification number725939
Number of Individuals Covered113
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $980
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $980
Insurance broker organization code?3
Insurance broker nameJAMES SLONAKER

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