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| Plan Name | FORTIS PAY |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | FORTIS PAYMENT SYSTEMS LLC |
| Employer identification number (EIN): | 273375894 |
| NAIC Classification: | 541990 |
| NAIC Description: | All Other Professional, Scientific, and Technical Services |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2023-12-01 | JONATHAN GOLDIN | |||
| 501 | 2022-12-01 | ||||
| 501 | 2022-12-01 | JONATHAN GOLDIN | |||
| 501 | 2021-12-01 | ||||
| 501 | 2021-12-01 | JONATHAN GOLDIN | |||
| 501 | 2020-12-01 | ||||
| 501 | 2020-12-01 | JONATHAN GOLDIN |
| 2022: FORTIS PAY 2022 form 5500 responses | ||
|---|---|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | Submission has been amended | No |
| 2022-12-01 | This submission is the final filing | No |
| 2022-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-12-01 | Plan is a collectively bargained plan | No |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: FORTIS PAY 2021 form 5500 responses | ||
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Submission has been amended | No |
| 2021-12-01 | This submission is the final filing | No |
| 2021-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-12-01 | Plan is a collectively bargained plan | No |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: FORTIS PAY 2020 form 5500 responses | ||
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | First time form 5500 has been submitted | Yes |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 1165134 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 404324 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 10769 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 5 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 757440 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 708318 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 641268 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 404324 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 404324 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 404324 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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| STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 641268 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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