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DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameDEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN
Plan identification number 501

DEVERE INSULATION COMPANY 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)
  • Other welfare benefit cover

401k Sponsoring company profile

DEVERE INSULATION COMPANY has sponsored the creation of one or more 401k plans.

Company Name:DEVERE INSULATION COMPANY
Employer identification number (EIN):521620251
NAIC Classification:238300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-12-01
5012019-12-01
5012018-12-01
5012017-12-01
5012016-12-01CHRIS RZEPKOWSKI
5012015-12-01CHRIS RZEPKOWSKI

Plan Statistics for DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN

401k plan membership statisitcs for DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN

Measure Date Value
2020: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-12-01233
Total number of active participants reported on line 7a of the Form 55002020-12-01274
Number of retired or separated participants receiving benefits2020-12-010
Number of other retired or separated participants entitled to future benefits2020-12-010
Total of all active and inactive participants2020-12-01274
2019: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-12-01209
Total number of active participants reported on line 7a of the Form 55002019-12-01198
Number of retired or separated participants receiving benefits2019-12-010
Number of other retired or separated participants entitled to future benefits2019-12-010
Total of all active and inactive participants2019-12-01198
2018: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-12-01243
Total number of active participants reported on line 7a of the Form 55002018-12-01240
Number of retired or separated participants receiving benefits2018-12-010
Number of other retired or separated participants entitled to future benefits2018-12-010
Total of all active and inactive participants2018-12-01240
2017: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01211
Total number of active participants reported on line 7a of the Form 55002017-12-01211
Number of retired or separated participants receiving benefits2017-12-010
Number of other retired or separated participants entitled to future benefits2017-12-010
Total of all active and inactive participants2017-12-01211
2016: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-12-01155
Total number of active participants reported on line 7a of the Form 55002016-12-01168
Number of retired or separated participants receiving benefits2016-12-010
Number of other retired or separated participants entitled to future benefits2016-12-010
Total of all active and inactive participants2016-12-01168
2015: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-12-01148
Total number of active participants reported on line 7a of the Form 55002015-12-01200
Number of retired or separated participants receiving benefits2015-12-010
Number of other retired or separated participants entitled to future benefits2015-12-010
Total of all active and inactive participants2015-12-01200

Form 5500 Responses for DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN

2020: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-12-01Type of plan entitySingle employer plan
2020-12-01Submission has been amendedNo
2020-12-01This submission is the final filingNo
2020-12-01This return/report is a short plan year return/report (less than 12 months)No
2020-12-01Plan is a collectively bargained planNo
2020-12-01Plan funding arrangement – InsuranceYes
2020-12-01Plan funding arrangement – General assets of the sponsorYes
2020-12-01Plan benefit arrangement – InsuranceYes
2020-12-01Plan benefit arrangement – General assets of the sponsorYes
2019: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-12-01Type of plan entitySingle employer plan
2019-12-01Submission has been amendedNo
2019-12-01This submission is the final filingNo
2019-12-01This return/report is a short plan year return/report (less than 12 months)No
2019-12-01Plan is a collectively bargained planNo
2019-12-01Plan funding arrangement – InsuranceYes
2019-12-01Plan benefit arrangement – InsuranceYes
2018: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-12-01Type of plan entitySingle employer plan
2018-12-01Submission has been amendedNo
2018-12-01This submission is the final filingNo
2018-12-01This return/report is a short plan year return/report (less than 12 months)No
2018-12-01Plan is a collectively bargained planNo
2018-12-01Plan funding arrangement – InsuranceYes
2018-12-01Plan benefit arrangement – InsuranceYes
2017: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01Submission has been amendedNo
2017-12-01This submission is the final filingNo
2017-12-01This return/report is a short plan year return/report (less than 12 months)No
2017-12-01Plan is a collectively bargained planNo
2017-12-01Plan funding arrangement – InsuranceYes
2017-12-01Plan benefit arrangement – InsuranceYes
2016: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-12-01Type of plan entitySingle employer plan
2016-12-01Submission has been amendedNo
2016-12-01This submission is the final filingNo
2016-12-01This return/report is a short plan year return/report (less than 12 months)No
2016-12-01Plan is a collectively bargained planNo
2016-12-01Plan funding arrangement – InsuranceYes
2016-12-01Plan benefit arrangement – InsuranceYes
2015: DEVERE INSULATION COMPANY HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-12-01Type of plan entitySingle employer plan
2015-12-01First time form 5500 has been submittedYes
2015-12-01Submission has been amendedNo
2015-12-01This submission is the final filingNo
2015-12-01This return/report is a short plan year return/report (less than 12 months)No
2015-12-01Plan is a collectively bargained planNo
2015-12-01Plan funding arrangement – InsuranceYes
2015-12-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0AN2D
Policy instance 3
Insurance contract or identification numberGUPR0AN2D
Number of Individuals Covered40
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $2,590
Total amount of fees paid to insurance companyUSD $1,614
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 BenefitYes
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 $18,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,590
Insurance broker organization code?3
Amount paid for insurance broker fees920
Additional information about fees paid to insurance brokerADMINISTRATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AN2D
Policy instance 2
Insurance contract or identification numberGUG0AN2D
Number of Individuals Covered64
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $1,768
Total amount of fees paid to insurance companyUSD $1,523
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 BenefitYes
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 $17,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,768
Insurance broker organization code?3
Amount paid for insurance broker fees884
Additional information about fees paid to insurance brokerADMINISTRATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AN2D
Policy instance 1
Insurance contract or identification numberGLUG0AN2D
Number of Individuals Covered283
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $4,926
Total amount of fees paid to insurance companyUSD $4,261
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $49,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,926
Insurance broker organization code?3
Amount paid for insurance broker fees2463
Additional information about fees paid to insurance brokerADMINISTRATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AN2D
Policy instance 3
Insurance contract or identification numberGUG0AN2D
Number of Individuals Covered51
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $1,594
Total amount of fees paid to insurance companyUSD $1,702
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 BenefitYes
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 $15,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,594
Amount paid for insurance broker fees797
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )
Policy contract numberIRSF
Policy instance 2
Insurance contract or identification numberIRSF
Number of Individuals Covered242
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $4,157
Total amount of fees paid to insurance companyUSD $80,399
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 BenefitYes
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 $1,088,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,157
Amount paid for insurance broker fees58252
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AN2D
Policy instance 1
Insurance contract or identification numberGLUG0AN2D
Number of Individuals Covered228
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $4,494
Total amount of fees paid to insurance companyUSD $4,827
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $43,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2580
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $4,494
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AN2D
Policy instance 3
Insurance contract or identification numberGUG0AN2D
Number of Individuals Covered55
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $1,511
Total amount of fees paid to insurance companyUSD $1,605
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 BenefitYes
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 $15,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,511
Amount paid for insurance broker fees849
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AN2D
Policy instance 1
Insurance contract or identification numberGLUG0AN2D
Number of Individuals Covered243
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $4,295
Total amount of fees paid to insurance companyUSD $4,593
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $42,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,295
Amount paid for insurance broker fees2147
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )
Policy contract numberIRSF
Policy instance 2
Insurance contract or identification numberIRSF
Number of Individuals Covered244
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $55,602
Total amount of fees paid to insurance companyUSD $20,635
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 BenefitYes
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 $1,116,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,602
Amount paid for insurance broker fees2035
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0AN2D
Policy instance 3
Insurance contract or identification numberGUG0AN2D
Number of Individuals Covered51
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $1,412
Total amount of fees paid to insurance companyUSD $782
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 BenefitYes
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 $13,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )
Policy contract numberIRSF
Policy instance 2
Insurance contract or identification numberIRSF
Number of Individuals Covered186
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $55,645
Total amount of fees paid to insurance companyUSD $17,186
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 BenefitYes
Dental Insurance Welfare BenefitYes
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 $1,073,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AN2D
Policy instance 1
Insurance contract or identification numberG000AN2D
Number of Individuals Covered249
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $4,083
Total amount of fees paid to insurance companyUSD $4,196
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $39,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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