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BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan NameBLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN
Plan identification number 501

BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BLACK DUCK SOFTWARE, INC. has sponsored the creation of one or more 401k plans.

Company Name:BLACK DUCK SOFTWARE, INC.
Employer identification number (EIN):320076720
NAIC Classification:334110

Additional information about BLACK DUCK SOFTWARE, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations
Incorporation Date: 1997-03-28
Company Identification Number: P97000028590
Legal Registered Office Address: 354 SOUTH WYMORE RD.

ALTAMONTE SPRINGS

32714

More information about BLACK DUCK SOFTWARE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012017-09-01
5012016-09-01
5012015-09-01MICHELLE GOODWIN
5012015-09-01
5012014-09-01MICHELLE GOODWIN MICHELLE GOODWIN2016-02-23
5012013-09-01MICHELL GOODWIN MICHELL GOODWIN2015-03-20
5012012-09-01MICHELLE GOODWIN

Plan Statistics for BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN

Measure Date Value
2017: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01213
Total number of active participants reported on line 7a of the Form 55002017-09-010
Number of retired or separated participants receiving benefits2017-09-010
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-010
2016: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01163
Total number of active participants reported on line 7a of the Form 55002016-09-01213
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01213
2015: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01163
Total number of active participants reported on line 7a of the Form 55002015-09-01163
Number of retired or separated participants receiving benefits2015-09-010
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01163
2014: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-01154
Total number of active participants reported on line 7a of the Form 55002014-09-01163
Total of all active and inactive participants2014-09-01163
2013: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-09-01151
Total number of active participants reported on line 7a of the Form 55002013-09-01154
Total of all active and inactive participants2013-09-01154
2012: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-09-01154
Total number of active participants reported on line 7a of the Form 55002012-09-01148
Number of retired or separated participants receiving benefits2012-09-013
Total of all active and inactive participants2012-09-01151

Form 5500 Responses for BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN

2017: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01This submission is the final filingYes
2017-09-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – InsuranceYes
2016: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – InsuranceYes
2015: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedYes
2015-09-01This submission is the final filingNo
2015-09-01This return/report is a short plan year return/report (less than 12 months)No
2015-09-01Plan is a collectively bargained planNo
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – InsuranceYes
2014: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-09-01Type of plan entitySingle employer plan
2014-09-01Submission has been amendedNo
2014-09-01This submission is the final filingNo
2014-09-01This return/report is a short plan year return/report (less than 12 months)No
2014-09-01Plan is a collectively bargained planNo
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan funding arrangement – General assets of the sponsorYes
2014-09-01Plan benefit arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – General assets of the sponsorYes
2013: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-09-01Type of plan entitySingle employer plan
2013-09-01Submission has been amendedNo
2013-09-01This submission is the final filingNo
2013-09-01This return/report is a short plan year return/report (less than 12 months)No
2013-09-01Plan is a collectively bargained planNo
2013-09-01Plan funding arrangement – InsuranceYes
2013-09-01Plan funding arrangement – General assets of the sponsorYes
2013-09-01Plan benefit arrangement – InsuranceYes
2013-09-01Plan benefit arrangement – General assets of the sponsorYes
2012: BLACK DUCK SOFTWARE, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-09-01Type of plan entitySingle employer plan
2012-09-01First time form 5500 has been submittedYes
2012-09-01Submission has been amendedNo
2012-09-01This submission is the final filingNo
2012-09-01This return/report is a short plan year return/report (less than 12 months)No
2012-09-01Plan is a collectively bargained planNo
2012-09-01Plan funding arrangement – InsuranceYes
2012-09-01Plan funding arrangement – General assets of the sponsorYes
2012-09-01Plan benefit arrangement – InsuranceYes
2012-09-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number403630000
Policy instance 9
Insurance contract or identification number403630000
Number of Individuals Covered489
Insurance policy start date2016-10-01
Insurance policy end date2017-09-30
Total amount of commissions paid to insurance brokerUSD $38,657
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $2,808,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $38,437
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05930641
Policy instance 1
Insurance contract or identification numberTM05930641
Number of Individuals Covered526
Insurance policy start date2016-10-01
Insurance policy end date2017-09-30
Total amount of commissions paid to insurance brokerUSD $5,416
Total amount of fees paid to insurance companyUSD $1,740
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $219,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,416
Amount paid for insurance broker fees1740
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98576571001
Policy instance 2
Insurance contract or identification number98576571001
Number of Individuals Covered335
Insurance policy start date2017-10-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $524
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,181
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $524
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number99076768
Policy instance 3
Insurance contract or identification number99076768
Number of Individuals Covered302
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $101
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $101
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWOODRUFF-SAWYER AND COMPANY
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05930641
Policy instance 4
Insurance contract or identification numberTM05930641
Number of Individuals Covered564
Insurance policy start date2017-10-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,982
Total amount of fees paid to insurance companyUSD $228
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,982
Amount paid for insurance broker fees228
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9576571001
Policy instance 5
Insurance contract or identification number9576571001
Number of Individuals Covered340
Insurance policy start date2016-10-01
Insurance policy end date2017-09-30
Total amount of commissions paid to insurance brokerUSD $1,829
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,304
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AVZ7
Policy instance 6
Insurance contract or identification numberGLUG0AVZ7
Number of Individuals Covered296
Insurance policy start date2016-10-01
Insurance policy end date2017-09-30
Total amount of commissions paid to insurance brokerUSD $13,239
Total amount of fees paid to insurance companyUSD $4,142
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $161,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,239
Amount paid for insurance broker fees4142
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AVZ7
Policy instance 7
Insurance contract or identification numberGLUG0AVZ7
Number of Individuals Covered302
Insurance policy start date2017-10-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,795
Total amount of fees paid to insurance companyUSD $4,142
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $49,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,795
Amount paid for insurance broker fees4142
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number403660000
Policy instance 8
Insurance contract or identification number403660000
Number of Individuals Covered494
Insurance policy start date2017-10-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $11,761
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $803,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,761
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number040363
Policy instance 4
Insurance contract or identification number040363
Number of Individuals Covered388
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $52,790
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,813,270
Commission paid to Insurance BrokerUSD $32,951
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9857657
Policy instance 5
Insurance contract or identification number9857657
Number of Individuals Covered186
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $626
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,541
Commission paid to Insurance BrokerUSD $565
Insurance broker organization code?3
Insurance broker nameEASTERN BENEFITS GROUP
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AVZ7
Policy instance 3
Insurance contract or identification numberG000AVZ7
Number of Individuals Covered163
Insurance policy start date2015-02-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $6,631
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,807
Commission paid to Insurance BrokerUSD $5,671
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number117275
Policy instance 2
Insurance contract or identification number117275
Number of Individuals Covered151
Insurance policy start date2014-09-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $2,888
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $34,206
Commission paid to Insurance BrokerUSD $2,460
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number000525
Policy instance 1
Insurance contract or identification number000525
Number of Individuals Covered352
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $4,254
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $169,960
Commission paid to Insurance BrokerUSD $838
Insurance broker organization code?3
Insurance broker nameEASTERN INSURANCE GROUP LLC
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number000525
Policy instance 1
Insurance contract or identification number000525
Number of Individuals Covered321
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $5,411
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $157,766
Commission paid to Insurance BrokerUSD $487
Insurance broker organization code?3
Insurance broker nameLONGFELLOW FINANCIAL LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number117275
Policy instance 2
Insurance contract or identification number117275
Number of Individuals Covered154
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $19,556
Total amount of fees paid to insurance companyUSD $2,333
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $86,299
Commission paid to Insurance BrokerUSD $19,556
Amount paid for insurance broker fees2084
Additional information about fees paid to insurance brokerCARRIER BONUS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number8007317
Policy instance 3
Insurance contract or identification number8007317
Number of Individuals Covered330
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $38,420
Total amount of fees paid to insurance companyUSD $10,030
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Commission paid to Insurance BrokerUSD $38,420
Amount paid for insurance broker fees10030
Additional information about fees paid to insurance brokerCARRIER BONUS
Insurance broker organization code?3
Insurance broker nameLONGFELLOW FINANCIAL
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9857657
Policy instance 4
Insurance contract or identification number9857657
Number of Individuals Covered125
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $626
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,541
Commission paid to Insurance BrokerUSD $61
Insurance broker organization code?3
Insurance broker nameLONGFELLOW BENEFITS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number117275
Policy instance 4
Insurance contract or identification number117275
Number of Individuals Covered79
Insurance policy start date2012-09-01
Insurance policy end date2013-09-01
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?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 BenefitYes
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 $44,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9857657
Policy instance 3
Insurance contract or identification number9857657
Number of Individuals Covered73
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $393
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 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 $4,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $393
Insurance broker organization code?3
Insurance broker nameLONGFELLOW BENEFITS
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number000525
Policy instance 2
Insurance contract or identification number000525
Number of Individuals Covered317
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $5,433
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 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 $155,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,433
Insurance broker organization code?3
Insurance broker nameLONGFELLOW FINANCIAL
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number8007317
Policy instance 1
Insurance contract or identification number8007317
Number of Individuals Covered306
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $36,684
Total amount of fees paid to insurance companyUSD $10,030
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 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 $36,684
Amount paid for insurance broker fees10030
Additional information about fees paid to insurance brokerBONUS AND PERSISTENCY
Insurance broker organization code?3
Insurance broker nameLONGFELLOW FINANCIAL

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