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RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 401k Plan overview

Plan NameRETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST
Plan identification number 501

RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Other welfare benefit cover

401k Sponsoring company profile

MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST has sponsored the creation of one or more 401k plans.

Company Name:MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST
Employer identification number (EIN):367705138
NAIC Classification:525920
NAIC Description:Trusts, Estates, and Agency Accounts

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01DENNIS FAULKNER2023-05-24
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01A1511606
5012017-06-29DENNIS FAULKNER, TRUSTEE

Plan Statistics for RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST

401k plan membership statisitcs for RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST

Measure Date Value
2021: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2021 401k membership
Total participants, beginning-of-year2021-01-01124
Total number of active participants reported on line 7a of the Form 55002021-01-0173
Total of all active and inactive participants2021-01-0173
2020: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2020 401k membership
Total participants, beginning-of-year2020-01-01130
Total number of active participants reported on line 7a of the Form 55002020-01-01124
Total of all active and inactive participants2020-01-01124
2019: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2019 401k membership
Total participants, beginning-of-year2019-01-01135
Total number of active participants reported on line 7a of the Form 55002019-01-01130
Total of all active and inactive participants2019-01-01130
2018: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2018 401k membership
Total participants, beginning-of-year2018-01-01153
Total number of active participants reported on line 7a of the Form 55002018-01-01135
Total of all active and inactive participants2018-01-01135
Total participants2018-01-01135
2017: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2017 401k membership
Total participants, beginning-of-year2017-06-29153
Total number of active participants reported on line 7a of the Form 55002017-06-29153
Total of all active and inactive participants2017-06-29153
Total participants2017-06-29153

Financial Data on RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST

Measure Date Value
2021 : RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2021 401k financial data
Total income from all sources (including contributions)2021-12-31$40,432
Total of all expenses incurred2021-12-31$188,026
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$99,463
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$40,104
Value of total assets at end of year2021-12-31$796,165
Value of total assets at beginning of year2021-12-31$943,759
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$88,563
Total interest from all sources2021-12-31$328
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Administrative expenses professional fees incurred2021-12-31$60,557
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$220,000
If this is an individual account plan, was there a blackout period2021-12-31No
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2021-12-31$99,463
Administrative expenses (other) incurred2021-12-31$432
Total non interest bearing cash at end of year2021-12-31$18,671
Total non interest bearing cash at beginning of year2021-12-31$41,593
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$-147,594
Value of net assets at end of year (total assets less liabilities)2021-12-31$796,165
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$943,759
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Investment advisory and management fees2021-12-31$4,000
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2021-12-31$777,494
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2021-12-31$328
Asset value of US Government securities at beginning of year2021-12-31$902,166
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31Yes
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$40,104
Contract administrator fees2021-12-31$23,574
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32021-12-31No
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31MCELROY & COMPANY
Accountancy firm EIN2021-12-31752682590
2020 : RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2020 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$28,337
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$33,657
Total income from all sources (including contributions)2020-12-31$55,827
Total of all expenses incurred2020-12-31$192,784
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$102,841
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$43,873
Value of total assets at end of year2020-12-31$959,929
Value of total assets at beginning of year2020-12-31$1,102,206
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$89,943
Total interest from all sources2020-12-31$11,954
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Administrative expenses professional fees incurred2020-12-31$56,668
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$220,000
If this is an individual account plan, was there a blackout period2020-12-31No
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Assets. Other investments not covered elsewhere at end of year2020-12-31$6,685
Assets. Other investments not covered elsewhere at beginning of year2020-12-31$7,659
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2020-12-31$102,841
Value of other receiveables (less allowance for doubtful accounts) at end of year2020-12-31$9,485
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2020-12-31$12,222
Administrative expenses (other) incurred2020-12-31$822
Liabilities. Value of operating payables at end of year2020-12-31$16,552
Liabilities. Value of operating payables at beginning of year2020-12-31$14,869
Total non interest bearing cash at end of year2020-12-31$41,593
Total non interest bearing cash at beginning of year2020-12-31$51,813
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$-136,957
Value of net assets at end of year (total assets less liabilities)2020-12-31$931,592
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$1,068,549
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Investment advisory and management fees2020-12-31$1,000
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2020-12-31$11,954
Asset value of US Government securities at end of year2020-12-31$902,166
Asset value of US Government securities at beginning of year2020-12-31$1,030,512
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31Yes
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$43,873
Contract administrator fees2020-12-31$31,453
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32020-12-31No
Liabilities. Value of benefit claims payable at end of year2020-12-31$11,785
Liabilities. Value of benefit claims payable at beginning of year2020-12-31$18,788
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31MCELROY & COMPANY
Accountancy firm EIN2020-12-31752682590
2019 : RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2019 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$33,657
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$24,781
Total income from all sources (including contributions)2019-12-31$74,543
Total of all expenses incurred2019-12-31$226,641
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$136,142
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$55,679
Value of total assets at end of year2019-12-31$1,102,206
Value of total assets at beginning of year2019-12-31$1,245,428
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$90,499
Total interest from all sources2019-12-31$18,864
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Administrative expenses professional fees incurred2019-12-31$57,715
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$220,000
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Assets. Other investments not covered elsewhere at end of year2019-12-31$7,659
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2019-12-31$136,142
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$12,222
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$16,887
Administrative expenses (other) incurred2019-12-31$534
Liabilities. Value of operating payables at end of year2019-12-31$14,869
Liabilities. Value of operating payables at beginning of year2019-12-31$11,101
Total non interest bearing cash at end of year2019-12-31$51,813
Total non interest bearing cash at beginning of year2019-12-31$216,893
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$-152,098
Value of net assets at end of year (total assets less liabilities)2019-12-31$1,068,549
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$1,220,647
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Investment advisory and management fees2019-12-31$1,000
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2019-12-31$18,864
Asset value of US Government securities at end of year2019-12-31$1,030,512
Asset value of US Government securities at beginning of year2019-12-31$1,011,648
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31Yes
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$55,679
Contract administrator fees2019-12-31$31,250
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-12-31No
Liabilities. Value of benefit claims payable at end of year2019-12-31$18,788
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$13,680
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31MCELROY & COMPANY
Accountancy firm EIN2019-12-31752682590
2018 : RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2018 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$24,781
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$33,936
Total income from all sources (including contributions)2018-12-31$77,509
Total of all expenses incurred2018-12-31$293,705
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$166,348
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$65,861
Value of total assets at end of year2018-12-31$1,245,428
Value of total assets at beginning of year2018-12-31$1,470,779
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$127,357
Total interest from all sources2018-12-31$11,648
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Administrative expenses professional fees incurred2018-12-31$93,521
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$220,000
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Assets. Other investments not covered elsewhere at beginning of year2018-12-31$9,391
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2018-12-31$166,348
Value of other receiveables (less allowance for doubtful accounts) at end of year2018-12-31$16,887
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2018-12-31$13,151
Administrative expenses (other) incurred2018-12-31$1,166
Liabilities. Value of operating payables at end of year2018-12-31$11,101
Liabilities. Value of operating payables at beginning of year2018-12-31$14,554
Total non interest bearing cash at end of year2018-12-31$216,893
Total non interest bearing cash at beginning of year2018-12-31$1,448,237
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$-216,196
Value of net assets at end of year (total assets less liabilities)2018-12-31$1,220,647
Value of net assets at beginning of year (total assets less liabilities)2018-12-31$1,436,843
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Investment advisory and management fees2018-12-31$1,000
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2018-12-31$11,648
Asset value of US Government securities at end of year2018-12-31$1,011,648
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contributions received in cash from employer2018-12-31$65,861
Contract administrator fees2018-12-31$31,670
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-12-31No
Liabilities. Value of benefit claims payable at end of year2018-12-31$13,680
Liabilities. Value of benefit claims payable at beginning of year2018-12-31$19,382
Did the plan have assets held for investment2018-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31No
Opinion of an independent qualified public accountant for this plan2018-12-31Unqualified
Accountancy firm name2018-12-31MCELROY & COMPANY
Accountancy firm EIN2018-12-31752682590
2017 : RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2017 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$33,936
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$0
Total income from all sources (including contributions)2017-12-31$1,610,123
Total of all expenses incurred2017-12-31$173,280
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2017-12-31$65,186
Total contributions o plan (from employers,participants, others, non cash contrinutions)2017-12-31$1,610,123
Value of total assets at end of year2017-12-31$1,470,779
Total of administrative expenses incurred including professional, contract, advisory and management fees2017-12-31$108,094
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Administrative expenses professional fees incurred2017-12-31$92,755
Was this plan covered by a fidelity bond2017-12-31Yes
Value of fidelity bond cover2017-12-31$220,000
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Assets. Other investments not covered elsewhere at end of year2017-12-31$9,391
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2017-12-31$65,186
Value of other receiveables (less allowance for doubtful accounts) at end of year2017-12-31$13,151
Administrative expenses (other) incurred2017-12-31$354
Liabilities. Value of operating payables at end of year2017-12-31$14,554
Liabilities. Value of operating payables at beginning of year2017-12-31$0
Total non interest bearing cash at end of year2017-12-31$1,448,237
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net income/loss2017-12-31$1,436,843
Value of net assets at end of year (total assets less liabilities)2017-12-31$1,436,843
Value of net assets at beginning of year (total assets less liabilities)2017-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Investment advisory and management fees2017-12-31$1,000
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Contributions received in cash from employer2017-12-31$1,610,123
Contract administrator fees2017-12-31$13,985
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-12-31No
Liabilities. Value of benefit claims payable at end of year2017-12-31$19,382
Liabilities. Value of benefit claims payable at beginning of year2017-12-31$0
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2017-12-31No
Opinion of an independent qualified public accountant for this plan2017-12-31Unqualified
Accountancy firm name2017-12-31MCELROY & COMPANY
Accountancy firm EIN2017-12-31752682590

Form 5500 Responses for RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST

2021: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement - TrustYes
2020: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement - TrustYes
2019: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement - TrustYes
2018: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – TrustYes
2018-01-01Plan benefit arrangement - TrustYes
2017: RETIREE HEALTH AND WELFARE PLAN OFFERED BY MAXUS RETIREES MODIFIED MEDICAL BENEFITS TRUST 2017 form 5500 responses
2017-06-29Type of plan entitySingle employer plan
2017-06-29First time form 5500 has been submittedYes
2017-06-29This return/report is a short plan year return/report (less than 12 months)Yes
2017-06-29Plan funding arrangement – TrustYes
2017-06-29Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

BENISTAR (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number01372
Policy instance 3
Insurance contract or identification number01372
Number of Individuals Covered14
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $45,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0655496
Policy instance 1
Insurance contract or identification number0655496
Number of Individuals Covered17
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BENISTAR (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number01372
Policy instance 3
Insurance contract or identification number01372
Number of Individuals Covered17
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $56,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0655496
Policy instance 1
Insurance contract or identification number0655496
Number of Individuals Covered20
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BENISTAR (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number01372
Policy instance 3
Insurance contract or identification number01372
Number of Individuals Covered20
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $67,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0655496
Policy instance 1
Insurance contract or identification number0655496
Number of Individuals Covered20
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BENISTAR (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number01372
Policy instance 3
Insurance contract or identification number01372
Number of Individuals Covered27
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $77,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0655496
Policy instance 1
Insurance contract or identification number0655496
Number of Individuals Covered23
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BENISTAR (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number01372
Policy instance 3
Insurance contract or identification number01372
Number of Individuals Covered28
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $24,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0655496
Policy instance 1
Insurance contract or identification number0655496
Number of Individuals Covered24
Insurance policy start date2017-07-15
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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