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FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan NameFAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN
Plan identification number 501

FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. has sponsored the creation of one or more 401k plans.

Company Name:FAMILY HEALTH SERVICES OF DARKE COUNTY, INC.
Employer identification number (EIN):341119524
NAIC Classification:621112
NAIC Description:Offices of Physicians, Mental Health Specialists

Additional information about FAMILY HEALTH SERVICES OF DARKE COUNTY, INC.

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division
Incorporation Date: 1973-01-16
Company Identification Number: 434419
Legal Registered Office Address: 5735 MEEKER ROAD
-
GREENVILLE
United States of America (USA)
45331

More information about FAMILY HEALTH SERVICES OF DARKE COUNTY, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-09-01JARED POLLICK2023-10-18
5012021-09-01JARED POLLICK2023-03-13
5012020-09-01JARED POLLICK2022-03-27
5012019-09-01JARED POLLICK2021-02-09
5012018-09-01JEAN YOUNG2019-12-30
5012017-09-01
5012016-09-01
5012015-09-01JEAN YOUNG
5012014-09-01JEAN YOUNG
5012013-09-01JEAN YOUNG
5012012-09-01JEAN YOUNG
5012011-09-01JEAN YOUNG

Plan Statistics for FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-09-01150
Total number of active participants reported on line 7a of the Form 55002022-09-01181
Number of retired or separated participants receiving benefits2022-09-010
Number of other retired or separated participants entitled to future benefits2022-09-010
Total of all active and inactive participants2022-09-01181
2021: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-01135
Total number of active participants reported on line 7a of the Form 55002021-09-01150
Number of retired or separated participants receiving benefits2021-09-010
Number of other retired or separated participants entitled to future benefits2021-09-010
Total of all active and inactive participants2021-09-01150
2020: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01159
Total number of active participants reported on line 7a of the Form 55002020-09-01135
Total of all active and inactive participants2020-09-01135
2019: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01152
Total number of active participants reported on line 7a of the Form 55002019-09-01158
Number of retired or separated participants receiving benefits2019-09-011
Total of all active and inactive participants2019-09-01159
2018: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01157
Total number of active participants reported on line 7a of the Form 55002018-09-01152
Total of all active and inactive participants2018-09-01152
2017: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01158
Total number of active participants reported on line 7a of the Form 55002017-09-01157
Total of all active and inactive participants2017-09-01157
2016: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01133
Total number of active participants reported on line 7a of the Form 55002016-09-01158
Total of all active and inactive participants2016-09-01158
2015: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01127
Total number of active participants reported on line 7a of the Form 55002015-09-01133
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 participants2015-09-01133
2014: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-01130
Total number of active participants reported on line 7a of the Form 55002014-09-01127
Number of retired or separated participants receiving benefits2014-09-010
Number of other retired or separated participants entitled to future benefits2014-09-010
Total of all active and inactive participants2014-09-01127
2013: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-09-01119
Total number of active participants reported on line 7a of the Form 55002013-09-01130
Number of retired or separated participants receiving benefits2013-09-010
Number of other retired or separated participants entitled to future benefits2013-09-010
Total of all active and inactive participants2013-09-01130
2012: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-09-01125
Total number of active participants reported on line 7a of the Form 55002012-09-01115
Number of retired or separated participants receiving benefits2012-09-014
Number of other retired or separated participants entitled to future benefits2012-09-010
Total of all active and inactive participants2012-09-01119
2011: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-09-01123
Total number of active participants reported on line 7a of the Form 55002011-09-01123
Number of retired or separated participants receiving benefits2011-09-012
Number of other retired or separated participants entitled to future benefits2011-09-010
Total of all active and inactive participants2011-09-01125

Form 5500 Responses for FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN

2022: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-09-01Type of plan entitySingle employer plan
2022-09-01Submission has been amendedNo
2022-09-01This submission is the final filingNo
2022-09-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-09-01Plan is a collectively bargained planNo
2022-09-01Plan funding arrangement – InsuranceYes
2022-09-01Plan funding arrangement – General assets of the sponsorYes
2022-09-01Plan benefit arrangement – InsuranceYes
2022-09-01Plan benefit arrangement – General assets of the sponsorYes
2021: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-09-01Type of plan entitySingle employer plan
2021-09-01Submission has been amendedNo
2021-09-01This submission is the final filingNo
2021-09-01This return/report is a short plan year return/report (less than 12 months)No
2021-09-01Plan is a collectively bargained planNo
2021-09-01Plan funding arrangement – InsuranceYes
2021-09-01Plan funding arrangement – General assets of the sponsorYes
2021-09-01Plan benefit arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – General assets of the sponsorYes
2020: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Submission has been amendedNo
2020-09-01This submission is the final filingNo
2020-09-01This return/report is a short plan year return/report (less than 12 months)No
2020-09-01Plan is a collectively bargained planNo
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan funding arrangement – General assets of the sponsorYes
2020-09-01Plan benefit arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – General assets of the sponsorYes
2019: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedNo
2019-09-01This submission is the final filingNo
2019-09-01This return/report is a short plan year return/report (less than 12 months)No
2019-09-01Plan is a collectively bargained planNo
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2018: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan funding arrangement – General assets of the sponsorYes
2018-09-01Plan benefit arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – General assets of the sponsorYes
2017: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan funding arrangement – General assets of the sponsorYes
2017-09-01Plan benefit arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – General assets of the sponsorYes
2016: FAMILY HEALTH SERVICES OF DARKE COUNTY, 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 funding arrangement – General assets of the sponsorYes
2016-09-01Plan benefit arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – General assets of the sponsorYes
2015: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedNo
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 funding arrangement – General assets of the sponsorYes
2015-09-01Plan benefit arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – General assets of the sponsorYes
2014: FAMILY HEALTH SERVICES OF DARKE COUNTY, 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 benefit arrangement – InsuranceYes
2013: FAMILY HEALTH SERVICES OF DARKE COUNTY, 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 benefit arrangement – InsuranceYes
2012: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-09-01Type of plan entitySingle employer plan
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 benefit arrangement – InsuranceYes
2011: FAMILY HEALTH SERVICES OF DARKE COUNTY, INC. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-09-01Type of plan entitySingle employer plan
2011-09-01First time form 5500 has been submittedYes
2011-09-01Submission has been amendedNo
2011-09-01This submission is the final filingNo
2011-09-01This return/report is a short plan year return/report (less than 12 months)No
2011-09-01Plan is a collectively bargained planNo
2011-09-01Plan funding arrangement – InsuranceYes
2011-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 2
Insurance contract or identification number767563G
Number of Individuals Covered181
Insurance policy start date2022-09-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $12,760
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
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 $127,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,325
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0928035
Policy instance 1
Insurance contract or identification number0928035
Number of Individuals Covered285
Insurance policy start date2022-09-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $16,308
Total amount of fees paid to insurance companyUSD $45,696
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 $1,637,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,308
Amount paid for insurance broker fees45696
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0928035
Policy instance 2
Insurance contract or identification number0928035
Number of Individuals Covered110
Insurance policy start date2022-06-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $10,890
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 $503,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees10890
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberL02953
Policy instance 1
Insurance contract or identification numberL02953
Number of Individuals Covered180
Insurance policy start date2021-09-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $34,962
Total amount of fees paid to insurance companyUSD $4,560
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 $694,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,962
Amount paid for insurance broker fees4560
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 4
Insurance contract or identification number767563G
Number of Individuals Covered150
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $13,243
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
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 $132,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,718
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0928035
Policy instance 3
Insurance contract or identification number0928035
Number of Individuals Covered71
Insurance policy start date2022-06-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $1,125
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,125
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 1
Insurance contract or identification number767563G
Number of Individuals Covered154
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $13,095
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $130,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,095
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 1
Insurance contract or identification number767563G
Number of Individuals Covered143
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $12,861
Total amount of fees paid to insurance companyUSD $670
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $128,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,861
Amount paid for insurance broker fees670
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 1
Insurance contract or identification number767563G
Number of Individuals Covered154
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $13,549
Total amount of fees paid to insurance companyUSD $591
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $135,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,549
Amount paid for insurance broker fees591
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number767563G
Policy instance 1
Insurance contract or identification number767563G
Number of Individuals Covered155
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $12,044
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $120,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,044
Insurance broker organization code?3
Insurance broker namePHELAN INSURANCE AGENCY

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