STONEHENGE CARE OF UTAH has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan STONEHENGE CARE LLC HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 259 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 340 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 340 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| Total participants, beginning-of-year | 2022-09-01 | 258 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 259 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 0 |
| Total of all active and inactive participants | 2022-09-01 | 259 |
| Number of employers contributing to the scheme | 2022-09-01 | 0 |
| 2021: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 258 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 258 |
| Number of employers contributing to the scheme | 2021-09-01 | 0 |
| 2020: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 287 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 242 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 242 |
| Number of employers contributing to the scheme | 2020-09-01 | 0 |
| 2019: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 289 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 286 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 287 |
| Number of employers contributing to the scheme | 2019-09-01 | 0 |
| 2018: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 304 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 158 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 158 |
| Number of employers contributing to the scheme | 2018-09-01 | 0 |
| 2017: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 345 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 170 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 170 |
| Number of employers contributing to the scheme | 2017-09-01 | 0 |
| 2016: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 349 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 349 |
| 2015: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 246 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 246 |
| 2014: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 100 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 100 |
| 2022: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: STONEHENGE CARE LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | First time form 5500 has been submitted | Yes |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | IJN UTZ511225 |
| Policy instance | 3 |
| Insurance contract or identification number | IJN UTZ511225 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $3,375 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,853 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,375 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 ) |
| Policy contract number | IJN8UTV1511255 |
| Policy instance | 2 |
| Insurance contract or identification number | IJN8UTV1511255 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $1,724 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,724 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 990-25-S4891 |
| Policy instance | 1 |
| Insurance contract or identification number | 990-25-S4891 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $11,146 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $61,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,431 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | IJNUT511225 |
| Policy instance | 3 |
| Insurance contract or identification number | IJNUT511225 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $233 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $233 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 ) |
| Policy contract number | IJN8UTV1511255 |
| Policy instance | 2 |
| Insurance contract or identification number | IJN8UTV1511255 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,979 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 990-25-S4891 |
| Policy instance | 1 |
| Insurance contract or identification number | 990-25-S4891 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $197 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $878 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $132 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 990-25-S4891 |
| Policy instance | 1 |
| Insurance contract or identification number | 990-25-S4891 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $2,851 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,901 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | IJNUT511225 |
| Policy instance | 3 |
| Insurance contract or identification number | IJNUT511225 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $3,188 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,188 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OPTICARE OF UTAH (National Association of Insurance Commissioners NAIC id number: 12533 ) |
| Policy contract number | IJN8UTV1511255 |
| Policy instance | 2 |
| Insurance contract or identification number | IJN8UTV1511255 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $1,255 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,255 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3341563 |
| Policy instance | 1 |
| Insurance contract or identification number | 3341563 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $7,856 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,856 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968526 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX968526 | | Number of Individuals Covered | 400 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $2,459 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $26,121 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,459 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 623184 |
| Policy instance | 1 |
| Insurance contract or identification number | 623184 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $8,666 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $147,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,666 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968526 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX968526 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $2,581 | | Total amount of fees paid to insurance company | USD $302 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $28,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,581 | | Amount paid for insurance broker fees | 302 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX968526 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX968526 | | Number of Individuals Covered | 290 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $2,736 | | Total amount of fees paid to insurance company | USD $771 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $30,704 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,736 | | Amount paid for insurance broker fees | 771 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 623184 |
| Policy instance | 1 |
| Insurance contract or identification number | 623184 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $9,399 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $161,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,399 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1067408 |
| Policy instance | 1 |
| Insurance contract or identification number | 1067408 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $15,452 | | Total amount of fees paid to insurance company | USD $2,051 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $211,789 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | UT300394 |
| Policy instance | 1 |
| Insurance contract or identification number | UT300394 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $15,449 | | Total amount of fees paid to insurance company | USD $3,231 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 Carrier | USD $216,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,449 | | Amount paid for insurance broker fees | 3231 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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