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EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 401k Plan overview

Plan NameEAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN
Plan identification number 504

EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY 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
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

EAGLE BURGMANN INDUSTRIES LP has sponsored the creation of one or more 401k plans.

Company Name:EAGLE BURGMANN INDUSTRIES LP
Employer identification number (EIN):371483702
NAIC Classification:339900

Additional information about EAGLE BURGMANN INDUSTRIES LP

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2004-07-07
Company Identification Number: 0800363666
Legal Registered Office Address: 47774 W ANCHOR CT

PLYMOUTH
United States of America (USA)
48170

More information about EAGLE BURGMANN INDUSTRIES LP

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042015-01-01MELISSA TUCKER
5042015-01-01
5042014-05-01BOZIDAR GRCEVIC
5042013-05-01BOZIDAR GRCEVIC
5042012-05-01BOZIDAR GRCEVIC
5042011-05-01BOZIDAR GRCEVIC
5042010-05-01BOZIDAR GRCEVIC
5042009-05-01BOZIDAR GRCEVIC
5042008-05-01BOZIDAR GRCEVIC
5042007-05-01BOZIDAR GRCEVIC

Plan Statistics for EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN

401k plan membership statisitcs for EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN

Measure Date Value
2015: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01180
Total number of active participants reported on line 7a of the Form 55002015-01-010
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-010
2014: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01184
Total number of active participants reported on line 7a of the Form 55002014-05-01180
Number of retired or separated participants receiving benefits2014-05-010
Number of other retired or separated participants entitled to future benefits2014-05-010
Total of all active and inactive participants2014-05-01180
2013: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01183
Total number of active participants reported on line 7a of the Form 55002013-05-01184
Number of retired or separated participants receiving benefits2013-05-010
Number of other retired or separated participants entitled to future benefits2013-05-010
Total of all active and inactive participants2013-05-01184
2012: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01177
Total number of active participants reported on line 7a of the Form 55002012-05-01183
Number of retired or separated participants receiving benefits2012-05-010
Number of other retired or separated participants entitled to future benefits2012-05-010
Total of all active and inactive participants2012-05-01183
2011: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01158
Total number of active participants reported on line 7a of the Form 55002011-05-01177
Number of retired or separated participants receiving benefits2011-05-010
Number of other retired or separated participants entitled to future benefits2011-05-010
Total of all active and inactive participants2011-05-01177
2010: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01135
Total number of active participants reported on line 7a of the Form 55002010-05-01158
Number of retired or separated participants receiving benefits2010-05-010
Number of other retired or separated participants entitled to future benefits2010-05-010
Total of all active and inactive participants2010-05-01158
2009: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-01133
Total number of active participants reported on line 7a of the Form 55002009-05-01135
Number of retired or separated participants receiving benefits2009-05-010
Number of other retired or separated participants entitled to future benefits2009-05-010
Total of all active and inactive participants2009-05-01135
2008: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2008 401k membership
Total participants, beginning-of-year2008-05-01155
Total number of active participants reported on line 7a of the Form 55002008-05-01133
Number of retired or separated participants receiving benefits2008-05-010
Number of other retired or separated participants entitled to future benefits2008-05-010
Total of all active and inactive participants2008-05-01133
2007: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2007 401k membership
Total participants, beginning-of-year2007-05-01110
Total number of active participants reported on line 7a of the Form 55002007-05-01155
Number of retired or separated participants receiving benefits2007-05-010
Number of other retired or separated participants entitled to future benefits2007-05-010
Total of all active and inactive participants2007-05-01155

Form 5500 Responses for EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN

2015: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedYes
2015-01-01This submission is the final filingYes
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedNo
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – InsuranceYes
2013: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – InsuranceYes
2012: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Submission has been amendedNo
2011-05-01This submission is the final filingNo
2011-05-01This return/report is a short plan year return/report (less than 12 months)No
2011-05-01Plan is a collectively bargained planNo
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Submission has been amendedNo
2010-05-01This submission is the final filingNo
2010-05-01This return/report is a short plan year return/report (less than 12 months)No
2010-05-01Plan is a collectively bargained planNo
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – InsuranceYes
2009: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01Submission has been amendedNo
2009-05-01This submission is the final filingNo
2009-05-01This return/report is a short plan year return/report (less than 12 months)No
2009-05-01Plan is a collectively bargained planNo
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – InsuranceYes
2008: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2008 form 5500 responses
2008-05-01Type of plan entitySingle employer plan
2008-05-01Submission has been amendedNo
2008-05-01This submission is the final filingNo
2008-05-01This return/report is a short plan year return/report (less than 12 months)No
2008-05-01Plan is a collectively bargained planNo
2008-05-01Plan funding arrangement – InsuranceYes
2008-05-01Plan benefit arrangement – InsuranceYes
2007: EAGLE BURGMANN INDUSTRIES LP LIFE, ADD AND DISABILITY PLAN 2007 form 5500 responses
2007-05-01Type of plan entitySingle employer plan
2007-05-01First time form 5500 has been submittedYes
2007-05-01Submission has been amendedNo
2007-05-01This submission is the final filingNo
2007-05-01This return/report is a short plan year return/report (less than 12 months)No
2007-05-01Plan is a collectively bargained planNo
2007-05-01Plan funding arrangement – InsuranceYes
2007-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number238418
Policy instance 1
Insurance contract or identification number238418
Number of Individuals Covered187
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $145
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered180
Insurance policy start date2014-05-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $10,425
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $95,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $10,425
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered184
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $3,212
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $149,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,125
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered183
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $13,030
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $164,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,458
Insurance broker organization code?3
Insurance broker nameBETTY L. BORNEMAN
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered177
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $2,906
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $139,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered158
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $9,495
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $96,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $9,495
Insurance broker organization code?3
Insurance broker nameBETTY L. BORNEMAN
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered135
Insurance policy start date2009-05-01
Insurance policy end date2010-04-30
Total amount of commissions paid to insurance brokerUSD $10,991
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $77,810
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $10,991
Insurance broker organization code?3
Insurance broker nameBETTY L. BORNEMAN
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered133
Insurance policy start date2008-05-01
Insurance policy end date2009-04-30
Total amount of commissions paid to insurance brokerUSD $9,132
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $85,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $9,132
Insurance broker organization code?3
Insurance broker nameBETTY L. BORNEMAN
SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )
Policy contract number021-1003-00
Policy instance 1
Insurance contract or identification number021-1003-00
Number of Individuals Covered155
Insurance policy start date2007-05-01
Insurance policy end date2008-04-30
Total amount of commissions paid to insurance brokerUSD $10,900
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $80,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $10,900
Insurance broker organization code?3
Insurance broker nameBETTY L. BORNEMAN

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