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SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan NameSOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN
Plan identification number 502

SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 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

SOUTHERN LEGACY WAFFLES, LLC has sponsored the creation of one or more 401k plans.

Company Name:SOUTHERN LEGACY WAFFLES, LLC
Employer identification number (EIN):453618413
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Additional information about SOUTHERN LEGACY WAFFLES, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5048848

More information about SOUTHERN LEGACY WAFFLES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-01-01
5022020-01-01
5022019-01-01
5022018-01-01
5022017-01-01JEFF ALLEN
5022016-01-01JEFF ALLEN

Plan Statistics for SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN

Measure Date Value
2022: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01184
Total number of active participants reported on line 7a of the Form 55002022-01-01196
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01196
2021: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01197
Total number of active participants reported on line 7a of the Form 55002021-01-01184
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01184
2020: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01203
Total number of active participants reported on line 7a of the Form 55002020-01-01197
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01197
2019: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01210
Total number of active participants reported on line 7a of the Form 55002019-01-01203
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01203
2018: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01155
Total number of active participants reported on line 7a of the Form 55002018-01-01210
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01210
2017: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-010
Total number of active participants reported on line 7a of the Form 55002017-01-010
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-010
2016: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-010
Total number of active participants reported on line 7a of the Form 55002016-01-010
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-010

Form 5500 Responses for SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN

2022: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: SOUTHERN LEGACY WAFFLES LLC FLEXIBLE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered17
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $306
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $306
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered32
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $265
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $265
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered102
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $3,224
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $32,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,224
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered63
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $5,743
Welfare Benefit Premiums Paid to CarrierUSD $114,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,743
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered196
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $1,302
Total amount of fees paid to insurance companyUSD $50,309
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $999,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,302
Amount paid for insurance broker fees50309
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered135
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $7,100
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $65,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,049
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered156
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $7,403
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,294
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered184
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $1,190
Total amount of fees paid to insurance companyUSD $46,111
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $917,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,188
Amount paid for insurance broker fees46092
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered64
Insurance policy start date2020-03-02
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $4,998
Welfare Benefit Premiums Paid to CarrierUSD $99,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,998
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered84
Insurance policy start date2020-03-02
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $2,372
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,372
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered28
Insurance policy start date2020-03-02
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $220
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $220
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered13
Insurance policy start date2020-03-02
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $228
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $228
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered153
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $6,520
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $63,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,793
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered197
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $1,356
Total amount of fees paid to insurance companyUSD $33,142
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,028,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,356
Amount paid for insurance broker fees33142
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered93
Insurance policy start date2019-03-04
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $6,676
Welfare Benefit Premiums Paid to CarrierUSD $133,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,676
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered115
Insurance policy start date2019-03-04
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $3,252
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $32,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,252
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered31
Insurance policy start date2019-03-04
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $256
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $256
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered16
Insurance policy start date2019-03-04
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $281
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $281
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-009345
Policy instance 7
Insurance contract or identification number136-009345
Number of Individuals Covered248
Insurance policy start date2019-11-01
Insurance policy end date2020-10-30
Total amount of commissions paid to insurance brokerUSD $1,447
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,294
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-009345
Policy instance 7
Insurance contract or identification number0135457
Number of Individuals Covered18631
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
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
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,423,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Vision Insurance Welfare BenefitYes
Commission paid to Insurance BrokerUSD $1,878
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered16
Insurance policy start date2018-03-05
Insurance policy end date2019-03-03
Total amount of commissions paid to insurance brokerUSD $329
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $329
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered38
Insurance policy start date2018-03-05
Insurance policy end date2019-03-03
Total amount of commissions paid to insurance brokerUSD $311
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $311
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered94
Insurance policy start date2018-03-05
Insurance policy end date2019-03-03
Total amount of commissions paid to insurance brokerUSD $2,914
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,914
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered92
Insurance policy start date2018-03-05
Insurance policy end date2019-03-03
Total amount of commissions paid to insurance brokerUSD $7,458
Welfare Benefit Premiums Paid to CarrierUSD $149,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,458
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered203
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $1,456
Total amount of fees paid to insurance companyUSD $36,606
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,233,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,456
Amount paid for insurance broker fees36606
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered154
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $8,141
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $70,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,087
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered147
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $6,787
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,878
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered210
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $1,611
Total amount of fees paid to insurance companyUSD $41,106
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,210,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,837
Amount paid for insurance broker fees41106
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered69
Insurance policy start date2017-03-02
Insurance policy end date2018-03-04
Total amount of commissions paid to insurance brokerUSD $5,001
Welfare Benefit Premiums Paid to CarrierUSD $100,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,001
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered61
Insurance policy start date2017-03-02
Insurance policy end date2018-03-04
Total amount of commissions paid to insurance brokerUSD $2,080
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,080
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered38
Insurance policy start date2017-03-02
Insurance policy end date2018-03-04
Total amount of commissions paid to insurance brokerUSD $344
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $344
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered16
Insurance policy start date2017-03-02
Insurance policy end date2018-03-04
Total amount of commissions paid to insurance brokerUSD $313
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $313
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-009345
Policy instance 7
Insurance contract or identification number0135457
Number of Individuals Covered18990
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
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
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,160,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Vision Insurance Welfare BenefitYes
Commission paid to Insurance BrokerUSD $1,878
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number705414
Policy instance 2
Insurance contract or identification number705414
Number of Individuals Covered155
Insurance policy start date2016-03-01
Insurance policy end date2017-02-28
Total amount of commissions paid to insurance brokerUSD $1,341
Total amount of fees paid to insurance companyUSD $27,787
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,114,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,341
Amount paid for insurance broker fees27787
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCM000911
Policy instance 3
Insurance contract or identification numberBCM000911
Number of Individuals Covered87
Insurance policy start date2016-03-03
Insurance policy end date2017-03-01
Total amount of commissions paid to insurance brokerUSD $9,243
Welfare Benefit Premiums Paid to CarrierUSD $84,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,300
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SVCS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCD000512
Policy instance 4
Insurance contract or identification numberBCD000512
Number of Individuals Covered115
Insurance policy start date2016-03-03
Insurance policy end date2017-03-01
Total amount of commissions paid to insurance brokerUSD $1,665
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,665
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCL000513
Policy instance 5
Insurance contract or identification numberBCL000513
Number of Individuals Covered53
Insurance policy start date2016-03-03
Insurance policy end date2017-03-01
Total amount of commissions paid to insurance brokerUSD $381
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $381
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberBCS000513
Policy instance 6
Insurance contract or identification numberBCS000513
Number of Individuals Covered35
Insurance policy start date2016-03-03
Insurance policy end date2017-03-01
Total amount of commissions paid to insurance brokerUSD $379
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $379
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number136-009345
Policy instance 7
Insurance contract or identification number136-009345
Number of Individuals Covered213
Insurance policy start date2016-11-01
Insurance policy end date2017-10-31
Total amount of commissions paid to insurance brokerUSD $1,281
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,188
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number044643G
Policy instance 1
Insurance contract or identification number044643G
Number of Individuals Covered142
Insurance policy start date2016-03-01
Insurance policy end date2017-02-28
Total amount of commissions paid to insurance brokerUSD $5,765
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,000
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SVCS

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