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C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameC4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN
Plan identification number 501

C4 THERAPEUTICS, INC. HEALTH AND WELFARE 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
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

C4 THERAPEUTICS INC has sponsored the creation of one or more 401k plans.

Company Name:C4 THERAPEUTICS INC
Employer identification number (EIN):475617627
NAIC Classification:541700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-01-01MELISSA EPSTEIN2024-07-19
5012022-01-01MELISSA EPSTEIN2023-09-28
5012021-01-01MELISSA EPSTEIN2022-08-17

Plan Statistics for C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2023: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year2023-01-01137
Total number of active participants reported on line 7a of the Form 55002023-01-01137
Number of retired or separated participants receiving benefits2023-01-011
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01138
Number of employers contributing to the scheme2023-01-010
2022: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01121
Total number of active participants reported on line 7a of the Form 55002022-01-01146
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01148
2021: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01104
Total number of active participants reported on line 7a of the Form 55002021-01-01123
Number of retired or separated participants receiving benefits2021-01-011
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01124

Form 5500 Responses for C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN

2023: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – InsuranceYes
2022: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: C4 THERAPEUTICS, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01First time form 5500 has been submittedYes
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number953977
Policy instance 5
Insurance contract or identification number953977
Number of Individuals Covered153
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $8,031
Total amount of fees paid to insurance companyUSD $2,915
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $136,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4960279
Policy instance 4
Insurance contract or identification number4960279
Number of Individuals Covered483
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $28,455
Total amount of fees paid to insurance companyUSD $7,193
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number1025901, 02
Policy instance 3
Insurance contract or identification number1025901, 02
Number of Individuals Covered335
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $1,724
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015058
Policy instance 2
Insurance contract or identification number015058
Number of Individuals Covered341
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $6,457
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $208,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number99086629
Policy instance 1
Insurance contract or identification number99086629
Number of Individuals Covered137
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $705
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $3,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5958739
Policy instance 6
Insurance contract or identification number5958739
Number of Individuals Covered131
Insurance policy start date2022-01-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $5,765
Total amount of fees paid to insurance companyUSD $1,186
Are there contracts with allocated funds for individual policies?0
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 & 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 $52,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,765
Amount paid for insurance broker fees1186
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number953977
Policy instance 5
Insurance contract or identification number953977
Number of Individuals Covered140
Insurance policy start date2022-07-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,254
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 $93,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,254
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4960279
Policy instance 4
Insurance contract or identification number4960279
Number of Individuals Covered465
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
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
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number1025901, 02
Policy instance 3
Insurance contract or identification number1025901, 02
Number of Individuals Covered321
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,629
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $17,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,629
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015058
Policy instance 2
Insurance contract or identification number015058
Number of Individuals Covered323
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $7,477
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $182,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,477
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number99086629
Policy instance 1
Insurance contract or identification number99086629
Number of Individuals Covered146
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
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 providedBUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5958739
Policy instance 7
Insurance contract or identification number5958739
Number of Individuals Covered115
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,576
Total amount of fees paid to insurance companyUSD $722
Are there contracts with allocated funds for individual policies?0
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 & 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 $96,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,463
Amount paid for insurance broker fees722
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION MARKETING FEES
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number105556
Policy instance 6
Insurance contract or identification number105556
Number of Individuals Covered6
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $708
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
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
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 $22,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $396
Insurance broker organization code?3
HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )
Policy contract number105555
Policy instance 5
Insurance contract or identification number105555
Number of Individuals Covered207
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $30,118
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
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
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 $936,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,844
Insurance broker organization code?3
HARVARD PILGRIM HEALTH CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96911 )
Policy contract number105554
Policy instance 4
Insurance contract or identification number105554
Number of Individuals Covered66
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,651
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
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
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 $331,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,957
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number1025901, 02
Policy instance 3
Insurance contract or identification number1025901, 02
Number of Individuals Covered259
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,447
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $13,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $847
Insurance broker organization code?3
DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 )
Policy contract number015058
Policy instance 2
Insurance contract or identification number015058
Number of Individuals Covered259
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,050
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $153,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,567
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number99086629
Policy instance 1
Insurance contract or identification number99086629
Number of Individuals Covered123
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
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 providedBUSINESS TRAVEL ACCIDENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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