401k Plan data: CARL E MELLEN & COMPANY 401K PLAN plan

CARL E MELLEN & COMPANY 401K PLAN 401k Plan overview

Plan Name	CARL E MELLEN & COMPANY 401K PLAN
Plan identification number	003

CARL E MELLEN & COMPANY 401K PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan covering Self-Employed individuals.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

CARL E. MELLEN & COMPANY 401 K PLAN has sponsored the creation of one or more 401k plans.

Company Name: CARL E. MELLEN & COMPANY 401 K PLAN

Employer identification number (EIN): 362098981

NAIC Classification: 524210
NAIC Description: Insurance Agencies and Brokerages

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CARL E MELLEN & COMPANY 401K PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2022-01-01 THOMAS POLL 2023-07-19
003 2021-01-01 THOMAS POLL 2022-06-21 THOMAS POLL 2022-06-21
003 2020-01-01 THOMAS POLL 2021-07-29 THOMAS POLL 2021-07-29
003 2019-01-01 THOMAS POLL 2020-06-26 THOMAS POLL 2020-06-26
003 2018-01-01 THOMAS POLL 2019-07-02
003 2017-01-01 THOMAS POLL 2018-06-15 THOMAS POLL 2018-06-15
003 2016-01-01 THOMAS POLL 2017-06-09 THOMAS POLL 2017-06-09
003 2015-01-01 THOMAS POLL 2016-07-01
003 2014-01-01 THOMAS POLL
003 2013-01-01 THOMAS POLL THOMAS POLL 2014-06-19
003 2012-01-01 THOMAS POLL
003 2011-01-01 THOMAS POLL
003 2010-01-01 THOMAS POLL
003 2009-01-01 THOMAS POLL THOMAS POLL 2010-09-16

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
003	2022-01-01	THOMAS POLL	2023-07-19
003	2021-01-01	THOMAS POLL	2022-06-21	THOMAS POLL	2022-06-21
003	2020-01-01	THOMAS POLL	2021-07-29	THOMAS POLL	2021-07-29
003	2019-01-01	THOMAS POLL	2020-06-26	THOMAS POLL	2020-06-26
003	2018-01-01	THOMAS POLL	2019-07-02
003	2017-01-01	THOMAS POLL	2018-06-15	THOMAS POLL	2018-06-15
003	2016-01-01	THOMAS POLL	2017-06-09	THOMAS POLL	2017-06-09
003	2015-01-01	THOMAS POLL	2016-07-01
003	2014-01-01	THOMAS POLL
003	2013-01-01	THOMAS POLL		THOMAS POLL	2014-06-19
003	2012-01-01	THOMAS POLL
003	2011-01-01	THOMAS POLL
003	2010-01-01	THOMAS POLL
003	2009-01-01	THOMAS POLL		THOMAS POLL	2010-09-16

Plan Statistics for CARL E MELLEN & COMPANY 401K PLAN

401k plan membership statisitcs for CARL E MELLEN & COMPANY 401K PLAN

Measure Date Value
2014: CARL E MELLEN & COMPANY 401K PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 14
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 11
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 13
Number of participants with account balances 2014-01-01 13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: CARL E MELLEN & COMPANY 401K PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 13
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 12
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 1
Total of all active and inactive participants 2013-01-01 13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 13
Number of participants with account balances 2013-01-01 12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: CARL E MELLEN & COMPANY 401K PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 13
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 12
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 1
Total of all active and inactive participants 2012-01-01 13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 13
Number of participants with account balances 2012-01-01 12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: CARL E MELLEN & COMPANY 401K PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 13
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 12
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 12
Number of participants with account balances 2011-01-01 12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: CARL E MELLEN & COMPANY 401K PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 12
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 10
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 3
Total of all active and inactive participants 2010-01-01 13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 13
Number of participants with account balances 2010-01-01 13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: CARL E MELLEN & COMPANY 401K PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 12
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 11
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 12
Number of participants with account balances 2009-01-01 12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: CARL E MELLEN & COMPANY 401K PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	14
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	11
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	13
Number of participants with account balances	2014-01-01	13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: CARL E MELLEN & COMPANY 401K PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	13
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	12
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	1
Total of all active and inactive participants	2013-01-01	13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	13
Number of participants with account balances	2013-01-01	12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: CARL E MELLEN & COMPANY 401K PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	13
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	12
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	1
Total of all active and inactive participants	2012-01-01	13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	13
Number of participants with account balances	2012-01-01	12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: CARL E MELLEN & COMPANY 401K PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	13
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	12
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	12
Number of participants with account balances	2011-01-01	12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: CARL E MELLEN & COMPANY 401K PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	12
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	10
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	3
Total of all active and inactive participants	2010-01-01	13
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	13
Number of participants with account balances	2010-01-01	13
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: CARL E MELLEN & COMPANY 401K PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	12
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	11
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	12
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	12
Number of participants with account balances	2009-01-01	12
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on CARL E MELLEN & COMPANY 401K PLAN

Measure	Date	Value
2014 : CARL E MELLEN & COMPANY 401K PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total income from all sources	2014-12-31	$195,730
Expenses. Total of all expenses incurred	2014-12-31	$307,452
Benefits paid (including direct rollovers)	2014-12-31	$307,360
Total plan assets at end of year	2014-12-31	$1,667,452
Total plan assets at beginning of year	2014-12-31	$1,779,174
Value of fidelity bond covering the plan	2014-12-31	$150,000
Total contributions received or receivable from participants	2014-12-31	$81,963
Expenses. Other expenses not covered elsewhere	2014-12-31	$92
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$82,430
Net income (gross income less expenses)	2014-12-31	$-111,722
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,667,452
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,779,174
Assets. Value of participant loans	2014-12-31	$795
Total contributions received or receivable from employer(s)	2014-12-31	$31,337
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : CARL E MELLEN & COMPANY 401K PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$334,704
Expenses. Total of all expenses incurred	2013-12-31	$136
Benefits paid (including direct rollovers)	2013-12-31	$0
Total plan assets at end of year	2013-12-31	$1,779,174
Total plan assets at beginning of year	2013-12-31	$1,444,606
Value of fidelity bond covering the plan	2013-12-31	$150,000
Total contributions received or receivable from participants	2013-12-31	$87,322
Expenses. Other expenses not covered elsewhere	2013-12-31	$136
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$215,080
Net income (gross income less expenses)	2013-12-31	$334,568
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,779,174
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,444,606
Assets. Value of participant loans	2013-12-31	$46,817
Total contributions received or receivable from employer(s)	2013-12-31	$32,302
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
2012 : CARL E MELLEN & COMPANY 401K PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$242,179
Expenses. Total of all expenses incurred	2012-12-31	$16,948
Benefits paid (including direct rollovers)	2012-12-31	$16,923
Total plan assets at end of year	2012-12-31	$1,444,606
Total plan assets at beginning of year	2012-12-31	$1,219,375
Value of fidelity bond covering the plan	2012-12-31	$150,000
Total contributions received or receivable from participants	2012-12-31	$76,099
Expenses. Other expenses not covered elsewhere	2012-12-31	$25
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$136,546
Net income (gross income less expenses)	2012-12-31	$225,231
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,444,606
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,219,375
Assets. Value of participant loans	2012-12-31	$0
Total contributions received or receivable from employer(s)	2012-12-31	$29,534
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0
2011 : CARL E MELLEN & COMPANY 401K PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$105,715
Expenses. Total of all expenses incurred	2011-12-31	$34,814
Benefits paid (including direct rollovers)	2011-12-31	$34,789
Total plan assets at end of year	2011-12-31	$1,219,375
Total plan assets at beginning of year	2011-12-31	$1,148,474
Value of fidelity bond covering the plan	2011-12-31	$150,000
Total contributions received or receivable from participants	2011-12-31	$70,377
Expenses. Other expenses not covered elsewhere	2011-12-31	$25
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$8,975
Net income (gross income less expenses)	2011-12-31	$70,901
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,219,375
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,148,474
Assets. Value of participant loans	2011-12-31	$0
Total contributions received or receivable from employer(s)	2011-12-31	$26,363
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2011-12-31	$0
Minimum employer required contribution for this plan year	2011-12-31	$0
Amount contributed by the employer to the plan for this plan year	2011-12-31	$0
2010 : CARL E MELLEN & COMPANY 401K PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$0
Total income from all sources	2010-12-31	$189,851
Expenses. Total of all expenses incurred	2010-12-31	$0
Benefits paid (including direct rollovers)	2010-12-31	$0
Total plan assets at end of year	2010-12-31	$1,148,474
Total plan assets at beginning of year	2010-12-31	$958,623
Value of fidelity bond covering the plan	2010-12-31	$150,000
Total contributions received or receivable from participants	2010-12-31	$61,903
Expenses. Other expenses not covered elsewhere	2010-12-31	$0
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$105,122
Net income (gross income less expenses)	2010-12-31	$189,851
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,148,474
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$958,623
Assets. Value of participant loans	2010-12-31	$0
Total contributions received or receivable from employer(s)	2010-12-31	$22,826
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0

Form 5500 Responses for CARL E MELLEN & COMPANY 401K PLAN

2014: CARL E MELLEN & COMPANY 401K PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CARL E MELLEN & COMPANY 401K PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CARL E MELLEN & COMPANY 401K PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CARL E MELLEN & COMPANY 401K PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: CARL E MELLEN & COMPANY 401K PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2009: CARL E MELLEN & COMPANY 401K PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-824533

Policy instance

Insurance contract or identification number	GA-824533
Number of Individuals Covered	13
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $3,574
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Broker	USD $3,574
Insurance broker organization code?	3
Insurance broker name	CARL E MELLEN & CO

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-824533

Policy instance

Insurance contract or identification number	GA-824533
Number of Individuals Covered	12
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,341
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-031017

Policy instance

Insurance contract or identification number	GA-031017
Number of Individuals Covered	13
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,941
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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?	Yes
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Broker	USD $1,941
Insurance broker organization code?	3
Insurance broker name	CARL E MELLEN & CO

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Company Name:	CARL E. MELLEN & COMPANY 401 K PLAN
Employer identification number (EIN):	362098981
NAIC Classification:	524210
NAIC Description:	Insurance Agencies and Brokerages