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FOOD STORE MANAGEMENT, INC. VEBA TRUST 401k Plan overview

Plan NameFOOD STORE MANAGEMENT, INC. VEBA TRUST
Plan identification number 501

FOOD STORE MANAGEMENT, INC. VEBA TRUST 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

401k Sponsoring company profile

FOOD STORE MANAGEMENT, INC has sponsored the creation of one or more 401k plans.

Company Name:FOOD STORE MANAGEMENT, INC
Employer identification number (EIN):341793372
NAIC Classification:561110
NAIC Description:Office Administrative Services

Additional information about FOOD STORE MANAGEMENT, INC

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division
Incorporation Date: 1995-02-02
Company Identification Number: 893037
Legal Registered Office Address: 100 FEDERAL PLAZA EAST, STE 600
-
YOUNGSTOWN
United States of America (USA)
44503

More information about FOOD STORE MANAGEMENT, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FOOD STORE MANAGEMENT, INC. VEBA TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012016-06-01
5012015-06-01
5012014-06-01
5012013-06-01
5012012-06-01HENRY NEMENZ
5012011-06-01HENRY NEMENZ
5012009-06-01HENRY NEMENZ

Plan Statistics for FOOD STORE MANAGEMENT, INC. VEBA TRUST

401k plan membership statisitcs for FOOD STORE MANAGEMENT, INC. VEBA TRUST

Measure Date Value
2016: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2016 401k membership
Total participants, beginning-of-year2016-06-0167
Total number of active participants reported on line 7a of the Form 55002016-06-0163
Total of all active and inactive participants2016-06-0163
2015: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2015 401k membership
Total participants, beginning-of-year2015-06-0173
Total number of active participants reported on line 7a of the Form 55002015-06-0167
Total of all active and inactive participants2015-06-0167
2014: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2014 401k membership
Total participants, beginning-of-year2014-06-0177
Total number of active participants reported on line 7a of the Form 55002014-06-0173
Total of all active and inactive participants2014-06-0173
2013: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2013 401k membership
Total participants, beginning-of-year2013-06-0187
Total number of active participants reported on line 7a of the Form 55002013-06-0177
Total of all active and inactive participants2013-06-0177
2012: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2012 401k membership
Total participants, beginning-of-year2012-06-01105
Total number of active participants reported on line 7a of the Form 55002012-06-0187
Total of all active and inactive participants2012-06-0187
2011: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2011 401k membership
Total participants, beginning-of-year2011-06-01112
Total number of active participants reported on line 7a of the Form 55002011-06-01105
Total of all active and inactive participants2011-06-01105
2009: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2009 401k membership
Total participants, beginning-of-year2009-06-01135
Total number of active participants reported on line 7a of the Form 55002009-06-01123
Total of all active and inactive participants2009-06-01123

Financial Data on FOOD STORE MANAGEMENT, INC. VEBA TRUST

Measure Date Value
2017 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2017 401k financial data
Total income from all sources2017-05-31$809,110
Expenses. Total of all expenses incurred2017-05-31$636,772
Benefits paid (including direct rollovers)2017-05-31$571,796
Total plan assets at end of year2017-05-31$237,594
Total plan assets at beginning of year2017-05-31$65,256
Value of fidelity bond covering the plan2017-05-31$60,000
Total contributions received or receivable from participants2017-05-31$453,625
Expenses. Other expenses not covered elsewhere2017-05-31$597
Net income (gross income less expenses)2017-05-31$172,338
Net plan assets at end of year (total assets less liabilities)2017-05-31$237,594
Net plan assets at beginning of year (total assets less liabilities)2017-05-31$65,256
Total contributions received or receivable from employer(s)2017-05-31$355,485
Expenses. Administrative service providers (salaries,fees and commissions)2017-05-31$64,379
2016 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2016 401k financial data
Total income from all sources2016-05-31$727,724
Expenses. Total of all expenses incurred2016-05-31$724,173
Benefits paid (including direct rollovers)2016-05-31$646,739
Total plan assets at end of year2016-05-31$65,256
Total plan assets at beginning of year2016-05-31$61,705
Value of fidelity bond covering the plan2016-05-31$60,000
Total contributions received or receivable from participants2016-05-31$155,481
Expenses. Other expenses not covered elsewhere2016-05-31$5,220
Net income (gross income less expenses)2016-05-31$3,551
Net plan assets at end of year (total assets less liabilities)2016-05-31$65,256
Net plan assets at beginning of year (total assets less liabilities)2016-05-31$61,705
Total contributions received or receivable from employer(s)2016-05-31$572,243
Expenses. Administrative service providers (salaries,fees and commissions)2016-05-31$72,214
2015 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2015 401k financial data
Total plan liabilities at end of year2015-05-31$0
Total plan liabilities at beginning of year2015-05-31$27,093
Total income from all sources2015-05-31$728,282
Expenses. Total of all expenses incurred2015-05-31$639,484
Benefits paid (including direct rollovers)2015-05-31$557,260
Total plan assets at end of year2015-05-31$61,705
Total plan assets at beginning of year2015-05-31$0
Value of fidelity bond covering the plan2015-05-31$60,000
Total contributions received or receivable from participants2015-05-31$152,946
Expenses. Other expenses not covered elsewhere2015-05-31$8,950
Net income (gross income less expenses)2015-05-31$88,798
Net plan assets at end of year (total assets less liabilities)2015-05-31$61,705
Net plan assets at beginning of year (total assets less liabilities)2015-05-31$-27,093
Total contributions received or receivable from employer(s)2015-05-31$575,336
Expenses. Administrative service providers (salaries,fees and commissions)2015-05-31$73,274
2014 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2014 401k financial data
Total plan liabilities at end of year2014-05-31$27,093
Total plan liabilities at beginning of year2014-05-31$975
Total income from all sources2014-05-31$581,579
Expenses. Total of all expenses incurred2014-05-31$829,207
Benefits paid (including direct rollovers)2014-05-31$731,276
Total plan assets at end of year2014-05-31$0
Total plan assets at beginning of year2014-05-31$221,510
Value of fidelity bond covering the plan2014-05-31$60,000
Total contributions received or receivable from participants2014-05-31$125,335
Expenses. Other expenses not covered elsewhere2014-05-31$435
Net income (gross income less expenses)2014-05-31$-247,628
Net plan assets at end of year (total assets less liabilities)2014-05-31$-27,093
Net plan assets at beginning of year (total assets less liabilities)2014-05-31$220,535
Total contributions received or receivable from employer(s)2014-05-31$456,244
Expenses. Administrative service providers (salaries,fees and commissions)2014-05-31$97,496
2013 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2013 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-05-31$975
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-05-31$49,952
Total income from all sources (including contributions)2013-05-31$951,938
Total of all expenses incurred2013-05-31$686,369
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-05-31$590,818
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-05-31$951,938
Value of total assets at end of year2013-05-31$221,510
Value of total assets at beginning of year2013-05-31$4,918
Total of administrative expenses incurred including professional, contract, advisory and management fees2013-05-31$95,551
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-05-31No
Administrative expenses professional fees incurred2013-05-31$11,884
Was this plan covered by a fidelity bond2013-05-31Yes
Value of fidelity bond cover2013-05-31$60,000
If this is an individual account plan, was there a blackout period2013-05-31No
Were there any nonexempt tranactions with any party-in-interest2013-05-31No
Contributions received from participants2013-05-31$116,098
Participant contributions at end of year2013-05-31$0
Participant contributions at beginning of year2013-05-31$4,918
Income. Received or receivable in cash from other sources (including rollovers)2013-05-31$1,486
Value of other receiveables (less allowance for doubtful accounts) at end of year2013-05-31$220,403
Administrative expenses (other) incurred2013-05-31$674
Liabilities. Value of operating payables at end of year2013-05-31$975
Liabilities. Value of operating payables at beginning of year2013-05-31$49,952
Total non interest bearing cash at end of year2013-05-31$1,107
Total non interest bearing cash at beginning of year2013-05-31$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-05-31No
Value of net income/loss2013-05-31$265,569
Value of net assets at end of year (total assets less liabilities)2013-05-31$220,535
Value of net assets at beginning of year (total assets less liabilities)2013-05-31$-45,034
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2013-05-31No
Were any leases to which the plan was party in default or uncollectible2013-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2013-05-31$244,320
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-05-31No
Was there a failure to transmit to the plan any participant contributions2013-05-31No
Has the plan failed to provide any benefit when due under the plan2013-05-31No
Contributions received in cash from employer2013-05-31$834,354
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2013-05-31$346,498
Contract administrator fees2013-05-31$82,993
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32013-05-31No
Did the plan have assets held for investment2013-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2013-05-31No
Opinion of an independent qualified public accountant for this plan2013-05-31Unqualified
Accountancy firm name2013-05-31HILL, BARTH & KING LLC
Accountancy firm EIN2013-05-31341897225
2012 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2012 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-05-31$49,952
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-05-31$58,180
Total income from all sources (including contributions)2012-05-31$852,517
Total of all expenses incurred2012-05-31$1,096,661
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2012-05-31$1,002,017
Total contributions o plan (from employers,participants, others, non cash contrinutions)2012-05-31$852,517
Value of total assets at end of year2012-05-31$4,918
Value of total assets at beginning of year2012-05-31$257,290
Total of administrative expenses incurred including professional, contract, advisory and management fees2012-05-31$94,644
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-05-31No
Administrative expenses professional fees incurred2012-05-31$11,900
Was this plan covered by a fidelity bond2012-05-31Yes
Value of fidelity bond cover2012-05-31$60,000
If this is an individual account plan, was there a blackout period2012-05-31No
Were there any nonexempt tranactions with any party-in-interest2012-05-31No
Contributions received from participants2012-05-31$105,063
Participant contributions at end of year2012-05-31$4,918
Participant contributions at beginning of year2012-05-31$4,429
Income. Received or receivable in cash from other sources (including rollovers)2012-05-31$8,556
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2012-05-31$252,861
Administrative expenses (other) incurred2012-05-31$540
Liabilities. Value of operating payables at end of year2012-05-31$49,952
Liabilities. Value of operating payables at beginning of year2012-05-31$58,180
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-05-31No
Value of net income/loss2012-05-31$-244,144
Value of net assets at end of year (total assets less liabilities)2012-05-31$-45,034
Value of net assets at beginning of year (total assets less liabilities)2012-05-31$199,110
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2012-05-31No
Were any leases to which the plan was party in default or uncollectible2012-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2012-05-31$213,465
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-05-31No
Was there a failure to transmit to the plan any participant contributions2012-05-31No
Has the plan failed to provide any benefit when due under the plan2012-05-31No
Contributions received in cash from employer2012-05-31$738,898
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2012-05-31$788,552
Contract administrator fees2012-05-31$82,204
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32012-05-31No
Did the plan have assets held for investment2012-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2012-05-31No
Opinion of an independent qualified public accountant for this plan2012-05-31Unqualified
Accountancy firm name2012-05-31HILL, BARTH & KING, LLC
Accountancy firm EIN2012-05-31341897225
2011 : FOOD STORE MANAGEMENT, INC. VEBA TRUST 2011 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2011-05-31$58,180
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2011-05-31$77,806
Total income from all sources (including contributions)2011-05-31$809,845
Total of all expenses incurred2011-05-31$877,612
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2011-05-31$824,805
Total contributions o plan (from employers,participants, others, non cash contrinutions)2011-05-31$809,845
Value of total assets at end of year2011-05-31$257,290
Value of total assets at beginning of year2011-05-31$344,683
Total of administrative expenses incurred including professional, contract, advisory and management fees2011-05-31$52,807
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2011-05-31No
Administrative expenses professional fees incurred2011-05-31$9,495
Was this plan covered by a fidelity bond2011-05-31Yes
Value of fidelity bond cover2011-05-31$60,000
If this is an individual account plan, was there a blackout period2011-05-31No
Were there any nonexempt tranactions with any party-in-interest2011-05-31No
Contributions received from participants2011-05-31$114,421
Participant contributions at end of year2011-05-31$4,429
Participant contributions at beginning of year2011-05-31$4,400
Income. Received or receivable in cash from other sources (including rollovers)2011-05-31$6,303
Value of other receiveables (less allowance for doubtful accounts) at end of year2011-05-31$252,861
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2011-05-31$340,283
Administrative expenses (other) incurred2011-05-31$584
Liabilities. Value of operating payables at end of year2011-05-31$58,180
Liabilities. Value of operating payables at beginning of year2011-05-31$77,806
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2011-05-31No
Value of net income/loss2011-05-31$-67,767
Value of net assets at end of year (total assets less liabilities)2011-05-31$199,110
Value of net assets at beginning of year (total assets less liabilities)2011-05-31$266,877
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2011-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2011-05-31No
Were any leases to which the plan was party in default or uncollectible2011-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2011-05-31$342,398
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2011-05-31No
Was there a failure to transmit to the plan any participant contributions2011-05-31No
Has the plan failed to provide any benefit when due under the plan2011-05-31No
Contributions received in cash from employer2011-05-31$689,121
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2011-05-31$482,407
Contract administrator fees2011-05-31$42,728
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32011-05-31No
Did the plan have assets held for investment2011-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2011-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2011-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2011-05-31No
Opinion of an independent qualified public accountant for this plan2011-05-31Unqualified
Accountancy firm name2011-05-31HILL, BARTH & KING, LLC
Accountancy firm EIN2011-05-31341897225

Form 5500 Responses for FOOD STORE MANAGEMENT, INC. VEBA TRUST

2016: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – TrustYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement - TrustYes
2015: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – TrustYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement - TrustYes
2014: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan funding arrangement – TrustYes
2014-06-01Plan benefit arrangement – InsuranceYes
2014-06-01Plan benefit arrangement - TrustYes
2013: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan funding arrangement – TrustYes
2013-06-01Plan benefit arrangement – InsuranceYes
2013-06-01Plan benefit arrangement - TrustYes
2012: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan funding arrangement – TrustYes
2012-06-01Plan benefit arrangement – InsuranceYes
2012-06-01Plan benefit arrangement - TrustYes
2011: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan funding arrangement – TrustYes
2011-06-01Plan benefit arrangement – InsuranceYes
2011-06-01Plan benefit arrangement - TrustYes
2009: FOOD STORE MANAGEMENT, INC. VEBA TRUST 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01This submission is the final filingNo
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan funding arrangement – TrustYes
2009-06-01Plan benefit arrangement – InsuranceYes
2009-06-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

TARTAN INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number
Policy instance 1
Number of Individuals Covered67
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $20,650
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number225148
Policy instance 1
Insurance contract or identification number225148
Number of Individuals Covered73
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number225148
Policy instance 1
Insurance contract or identification number225148
Number of Individuals Covered77
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $99,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
US FIRE (National Association of Insurance Commissioners NAIC id number: 21113 )
Policy contract numberUS000331
Policy instance 2
Insurance contract or identification numberUS000331
Number of Individuals Covered77
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $52,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number225148
Policy instance 1
Insurance contract or identification number225148
Number of Individuals Covered87
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberCLI-70521
Policy instance 2
Insurance contract or identification numberCLI-70521
Number of Individuals Covered87
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number05CL180026
Policy instance 1
Insurance contract or identification number05CL180026
Number of Individuals Covered105
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $6,354
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number05CL180026
Policy instance 2
Insurance contract or identification number05CL180026
Number of Individuals Covered105
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $15,192
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number05CL180026
Policy instance 1
Insurance contract or identification number05CL180026
Number of Individuals Covered112
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $26,193
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
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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