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STONERISE HEALTHCARE LLC MEDICAL PLAN 401k Plan overview

Plan NameSTONERISE HEALTHCARE LLC MEDICAL PLAN
Plan identification number 501

STONERISE HEALTHCARE LLC MEDICAL 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)
  • Other welfare benefit cover

401k Sponsoring company profile

STONERISE HEALTHCARE, LLC has sponsored the creation of one or more 401k plans.

Company Name:STONERISE HEALTHCARE, LLC
Employer identification number (EIN):270602445
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STONERISE HEALTHCARE LLC MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-05-01
5012020-05-01
5012019-05-01
5012018-05-01
5012017-05-01JESSICA HUDSON
5012016-05-01
5012015-05-01
5012015-05-01
5012014-05-01
5012014-05-01JESSICA HUDSON2018-11-13
5012013-05-01JESSICA HUDSON
5012012-05-01
5012011-05-01
5012010-05-01
5012009-05-01
5012008-05-01

Plan Statistics for STONERISE HEALTHCARE LLC MEDICAL PLAN

401k plan membership statisitcs for STONERISE HEALTHCARE LLC MEDICAL PLAN

Measure Date Value
2020: STONERISE HEALTHCARE LLC MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-011,379
Total number of active participants reported on line 7a of the Form 55002020-05-011,342
Number of retired or separated participants receiving benefits2020-05-010
Number of other retired or separated participants entitled to future benefits2020-05-010
Total of all active and inactive participants2020-05-011,342
2019: STONERISE HEALTHCARE LLC MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-011,478
Total number of active participants reported on line 7a of the Form 55002019-05-011,330
Number of retired or separated participants receiving benefits2019-05-0124
Number of other retired or separated participants entitled to future benefits2019-05-010
Total of all active and inactive participants2019-05-011,354
2018: STONERISE HEALTHCARE LLC MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-011,363
Total number of active participants reported on line 7a of the Form 55002018-05-011,394
Number of retired or separated participants receiving benefits2018-05-017
Number of other retired or separated participants entitled to future benefits2018-05-010
Total of all active and inactive participants2018-05-011,401
2017: STONERISE HEALTHCARE LLC MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-011,719
Total number of active participants reported on line 7a of the Form 55002017-05-012,087
Number of retired or separated participants receiving benefits2017-05-0118
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-012,105
2016: STONERISE HEALTHCARE LLC MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-011,547
Total number of active participants reported on line 7a of the Form 55002016-05-011,436
Number of retired or separated participants receiving benefits2016-05-013
Number of other retired or separated participants entitled to future benefits2016-05-010
Total of all active and inactive participants2016-05-011,439
2015: STONERISE HEALTHCARE LLC MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01444
Total number of active participants reported on line 7a of the Form 55002015-05-01990
Total of all active and inactive participants2015-05-01990
Number of retired or separated participants receiving benefits2015-05-013
Number of other retired or separated participants entitled to future benefits2015-05-010
2014: STONERISE HEALTHCARE LLC MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01283
Total number of active participants reported on line 7a of the Form 55002014-05-01444
Total of all active and inactive participants2014-05-01444
Number of retired or separated participants receiving benefits2014-05-011
Number of other retired or separated participants entitled to future benefits2014-05-010
2013: STONERISE HEALTHCARE LLC MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01217
Total number of active participants reported on line 7a of the Form 55002013-05-01278
Number of retired or separated participants receiving benefits2013-05-010
Number of other retired or separated participants entitled to future benefits2013-05-010
Total of all active and inactive participants2013-05-01278
2012: STONERISE HEALTHCARE LLC MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01123
Total of all active and inactive participants2012-05-010
2011: STONERISE HEALTHCARE LLC MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01122
2010: STONERISE HEALTHCARE LLC MEDICAL PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01118
2009: STONERISE HEALTHCARE LLC MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-0191
2008: STONERISE HEALTHCARE LLC MEDICAL PLAN 2008 401k membership
Total participants, beginning-of-year2008-05-010

Financial Data on STONERISE HEALTHCARE LLC MEDICAL PLAN

Measure Date Value
2016 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2016 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-04-30No
Was this plan covered by a fidelity bond2016-04-30No
If this is an individual account plan, was there a blackout period2016-04-30No
Were there any nonexempt tranactions with any party-in-interest2016-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2016-04-30No
Were any leases to which the plan was party in default or uncollectible2016-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-04-30No
Was there a failure to transmit to the plan any participant contributions2016-04-30No
Has the plan failed to provide any benefit when due under the plan2016-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32016-04-30No
Did the plan have assets held for investment2016-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-04-30No
2013 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets2013-04-30$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-04-30$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-04-30$0
Total income from all sources (including contributions)2013-04-30$0
Total loss/gain on sale of assets2013-04-30$0
Total of all expenses incurred2013-04-30$0
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-04-30$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-04-30$0
Value of total assets at end of year2013-04-30$0
Value of total assets at beginning of year2013-04-30$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2013-04-30$0
Total interest from all sources2013-04-30$0
Total dividends received (eg from common stock, registered investment company shares)2013-04-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-04-30No
Was this plan covered by a fidelity bond2013-04-30No
If this is an individual account plan, was there a blackout period2013-04-30No
Were there any nonexempt tranactions with any party-in-interest2013-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-04-30No
Value of net income/loss2013-04-30$0
Value of net assets at end of year (total assets less liabilities)2013-04-30$0
Value of net assets at beginning of year (total assets less liabilities)2013-04-30$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2013-04-30No
Were any leases to which the plan was party in default or uncollectible2013-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-04-30No
Was there a failure to transmit to the plan any participant contributions2013-04-30No
Has the plan failed to provide any benefit when due under the plan2013-04-30No
Did the plan have assets held for investment2013-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-04-30No
2012 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2012 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-04-30No
Was this plan covered by a fidelity bond2012-04-30No
If this is an individual account plan, was there a blackout period2012-04-30No
Were there any nonexempt tranactions with any party-in-interest2012-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2012-04-30No
Were any leases to which the plan was party in default or uncollectible2012-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-04-30No
Was there a failure to transmit to the plan any participant contributions2012-04-30No
Has the plan failed to provide any benefit when due under the plan2012-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32012-04-30No
Did the plan have assets held for investment2012-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-04-30No
2011 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2011 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2011-04-30No
Was this plan covered by a fidelity bond2011-04-30No
If this is an individual account plan, was there a blackout period2011-04-30No
Were there any nonexempt tranactions with any party-in-interest2011-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2011-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2011-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2011-04-30No
Were any leases to which the plan was party in default or uncollectible2011-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2011-04-30No
Was there a failure to transmit to the plan any participant contributions2011-04-30No
Has the plan failed to provide any benefit when due under the plan2011-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32011-04-30No
Did the plan have assets held for investment2011-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2011-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2011-04-30No
2010 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2010 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2010-04-30No
Was this plan covered by a fidelity bond2010-04-30No
If this is an individual account plan, was there a blackout period2010-04-30No
Were there any nonexempt tranactions with any party-in-interest2010-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2010-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2010-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2010-04-30No
Were any leases to which the plan was party in default or uncollectible2010-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2010-04-30No
Was there a failure to transmit to the plan any participant contributions2010-04-30No
Has the plan failed to provide any benefit when due under the plan2010-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32010-04-30No
Did the plan have assets held for investment2010-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2010-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2010-04-30No
2009 : STONERISE HEALTHCARE LLC MEDICAL PLAN 2009 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2009-04-30No
Was this plan covered by a fidelity bond2009-04-30No
If this is an individual account plan, was there a blackout period2009-04-30No
Were there any nonexempt tranactions with any party-in-interest2009-04-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2009-04-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2009-04-30No
Were any loans by the plan or fixed income obligations due to the plan in default2009-04-30No
Were any leases to which the plan was party in default or uncollectible2009-04-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2009-04-30No
Was there a failure to transmit to the plan any participant contributions2009-04-30No
Has the plan failed to provide any benefit when due under the plan2009-04-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32009-04-30No
Did the plan have assets held for investment2009-04-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2009-04-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2009-04-30No

Form 5500 Responses for STONERISE HEALTHCARE LLC MEDICAL PLAN

2020: STONERISE HEALTHCARE LLC MEDICAL PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedYes
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan funding arrangement – General assets of the sponsorYes
2020-05-01Plan benefit arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – General assets of the sponsorYes
2019: STONERISE HEALTHCARE LLC MEDICAL PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Submission has been amendedNo
2019-05-01This submission is the final filingNo
2019-05-01This return/report is a short plan year return/report (less than 12 months)No
2019-05-01Plan is a collectively bargained planNo
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – General assets of the sponsorYes
2018: STONERISE HEALTHCARE LLC MEDICAL PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Submission has been amendedNo
2018-05-01This submission is the final filingNo
2018-05-01This return/report is a short plan year return/report (less than 12 months)No
2018-05-01Plan is a collectively bargained planNo
2018-05-01Plan funding arrangement – General assets of the sponsorYes
2018-05-01Plan benefit arrangement – General assets of the sponsorYes
2017: STONERISE HEALTHCARE LLC MEDICAL PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Submission has been amendedNo
2017-05-01This submission is the final filingNo
2017-05-01This return/report is a short plan year return/report (less than 12 months)No
2017-05-01Plan is a collectively bargained planNo
2017-05-01Plan funding arrangement – General assets of the sponsorYes
2017-05-01Plan benefit arrangement – General assets of the sponsorYes
2016: STONERISE HEALTHCARE LLC MEDICAL PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes
2015: STONERISE HEALTHCARE LLC MEDICAL PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Submission has been amendedYes
2015-05-01This submission is the final filingNo
2015-05-01This return/report is a short plan year return/report (less than 12 months)No
2015-05-01Plan is a collectively bargained planNo
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan funding arrangement – General assets of the sponsorYes
2015-05-01Plan benefit arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – General assets of the sponsorYes
2014: STONERISE HEALTHCARE LLC MEDICAL PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedYes
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)No
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan funding arrangement – General assets of the sponsorYes
2014-05-01Plan benefit arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – General assets of the sponsorYes
2013: STONERISE HEALTHCARE LLC MEDICAL PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01First time form 5500 has been submittedYes
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – InsuranceYes
2012: STONERISE HEALTHCARE LLC MEDICAL PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: STONERISE HEALTHCARE LLC MEDICAL PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: STONERISE HEALTHCARE LLC MEDICAL PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – InsuranceYes
2009: STONERISE HEALTHCARE LLC MEDICAL PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – InsuranceYes
2008: STONERISE HEALTHCARE LLC MEDICAL PLAN 2008 form 5500 responses
2008-05-01Type of plan entitySingle employer plan
2008-05-01First time form 5500 has been submittedYes
2008-05-01Plan funding arrangement – InsuranceYes
2008-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0214435
Policy instance 1
Insurance contract or identification number0214435
Number of Individuals Covered3250
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $112,446
Total amount of fees paid to insurance companyUSD $44,690
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 BenefitYes
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 $1,225,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $112,446
Amount paid for insurance broker fees44690
Additional information about fees paid to insurance brokerSERVICE FEES AND SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0214435
Policy instance 1
Insurance contract or identification number0214435
Number of Individuals Covered3349
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $131,193
Total amount of fees paid to insurance companyUSD $57,113
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 BenefitYes
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 $1,289,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $131,193
Amount paid for insurance broker fees57113
Additional information about fees paid to insurance brokerSERVICE FEES AND SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered990
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $28
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30
Insurance broker nameJACK GRIMM
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered1505
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $45,343
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,343
Insurance broker nameRICK BURKA
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered1049
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $27,156
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,156
Insurance broker nameRICK BURKA
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered444
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $24,096
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,066
Insurance broker nameRICK BURKA
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number106890
Policy instance 1
Insurance contract or identification number106890
Number of Individuals Covered433
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $61,609
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 $1,940,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,609
Insurance broker organization code?3
Insurance broker nameJACK GRIMM
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered295
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $7,041
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,041
Insurance broker organization code?3
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered194
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $157
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered193
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $3,042
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,042
Insurance broker nameRICK BURKA
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered205
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $766
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $766
Insurance broker nameROSS JOHNSON
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered192
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $523
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $523
Insurance broker nameRICK BURKA
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered195
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $3,994
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,994
Insurance broker nameRICK BURKA
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered190
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered142
Insurance policy start date2009-02-01
Insurance policy end date2010-01-31
Total amount of commissions paid to insurance brokerUSD $4,948
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,523
Insurance broker nameLIFETIME FINANCIAL GROWTH
HIGHMARK WEST VIRGINIA (National Association of Insurance Commissioners NAIC id number: 54828 )
Policy contract number09098177
Policy instance 1
Insurance contract or identification number09098177
Number of Individuals Covered142
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00435213
Policy instance 2
Insurance contract or identification number00435213
Number of Individuals Covered142
Insurance policy start date2008-01-31
Insurance policy end date2009-02-01
Total amount of commissions paid to insurance brokerUSD $4,736
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,406
Insurance broker nameLIFETIME FINANCIAL GROWTH

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