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CURTIS BAY ENERGY, INC. 401k Plan overview

Plan NameCURTIS BAY ENERGY, INC.
Plan identification number 503

CURTIS BAY ENERGY, INC. 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

CURTIS BAY ENERGY, INC. has sponsored the creation of one or more 401k plans.

Company Name:CURTIS BAY ENERGY, INC.
Employer identification number (EIN):521770031
NAIC Classification:562000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CURTIS BAY ENERGY, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032023-03-01ROLANDO VAZQUEZ2024-09-16
5032023-01-01ROLANDO VAZQUEZ2024-02-28
5032022-01-01ROLANDO VAZQUEZ2023-06-13
5032021-01-01ROLANDO VAZQUEZ2022-10-11
5032020-01-01ROLANDO VAZQUEZ2022-10-11
5032019-01-01
5032018-01-01
5032017-01-01DEBBIE MARTIN DEBBIE MARTIN2018-12-05

Plan Statistics for CURTIS BAY ENERGY, INC.

401k plan membership statisitcs for CURTIS BAY ENERGY, INC.

Measure Date Value
2023: CURTIS BAY ENERGY, INC. 2023 401k membership
Total participants, beginning-of-year2023-03-01278
Total number of active participants reported on line 7a of the Form 55002023-03-01270
Number of retired or separated participants receiving benefits2023-03-010
Number of other retired or separated participants entitled to future benefits2023-03-010
Total of all active and inactive participants2023-03-01270
Number of employers contributing to the scheme2023-03-010
Total participants, beginning-of-year2023-01-01264
Total number of active participants reported on line 7a of the Form 55002023-01-01278
Number of retired or separated participants receiving benefits2023-01-010
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01278
Number of employers contributing to the scheme2023-01-010
2022: CURTIS BAY ENERGY, INC. 2022 401k membership
Total participants, beginning-of-year2022-01-01206
Total number of active participants reported on line 7a of the Form 55002022-01-01264
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 participants2022-01-01264
Number of employers contributing to the scheme2022-01-010
2021: CURTIS BAY ENERGY, INC. 2021 401k membership
Total participants, beginning-of-year2021-01-01163
Total number of active participants reported on line 7a of the Form 55002021-01-01206
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 participants2021-01-01206
Number of employers contributing to the scheme2021-01-010
2020: CURTIS BAY ENERGY, INC. 2020 401k membership
Total participants, beginning-of-year2020-01-01197
Total number of active participants reported on line 7a of the Form 55002020-01-01163
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 participants2020-01-01163
Number of employers contributing to the scheme2020-01-010
2019: CURTIS BAY ENERGY, INC. 2019 401k membership
Total participants, beginning-of-year2019-01-01193
Total number of active participants reported on line 7a of the Form 55002019-01-01197
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 participants2019-01-01197
Total participants2019-01-01197
Number of employers contributing to the scheme2019-01-010
2018: CURTIS BAY ENERGY, INC. 2018 401k membership
Total participants, beginning-of-year2018-01-01197
Total number of active participants reported on line 7a of the Form 55002018-01-01193
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 participants2018-01-01193
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2018-01-010
Total participants2018-01-01193
Number of participants with account balances2018-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2018-01-010
Number of employers contributing to the scheme2018-01-010
2017: CURTIS BAY ENERGY, INC. 2017 401k membership
Total participants, beginning-of-year2017-01-01152
Total number of active participants reported on line 7a of the Form 55002017-01-01189
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 participants2017-01-01189
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2017-01-011
Total participants2017-01-01190
Number of participants with account balances2017-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2017-01-010
Number of employers contributing to the scheme2017-01-010

Form 5500 Responses for CURTIS BAY ENERGY, INC.

2023: CURTIS BAY ENERGY, INC. 2023 form 5500 responses
2023-03-01Type of plan entitySingle employer plan
2023-03-01Plan funding arrangement – InsuranceYes
2023-03-01Plan benefit arrangement – InsuranceYes
2023-01-01Type of plan entitySingle employer plan
2023-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – InsuranceYes
2022: CURTIS BAY ENERGY, INC. 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: CURTIS BAY ENERGY, INC. 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: CURTIS BAY ENERGY, INC. 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: CURTIS BAY ENERGY, INC. 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: CURTIS BAY ENERGY, INC. 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: CURTIS BAY ENERGY, INC. 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number930891
Policy instance 1
Insurance contract or identification number930891
Number of Individuals Covered636
Insurance policy start date2023-03-01
Insurance policy end date2024-02-29
Total amount of commissions paid to insurance brokerUSD $20,149
Total amount of fees paid to insurance companyUSD $153,223
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,206,323
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 numberGLUG0AW7Z
Policy instance 2
Insurance contract or identification numberGLUG0AW7Z
Number of Individuals Covered278
Insurance policy start date2023-01-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $748
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $38,226
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 number2KA8
Policy instance 1
Insurance contract or identification number2KA8
Number of Individuals Covered342
Insurance policy start date2023-01-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $222
Total amount of fees paid to insurance companyUSD $16,050
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $343,258
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 numberGLTD0AW7Z
Policy instance 2
Insurance contract or identification numberGLTD0AW7Z
Number of Individuals Covered264
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $13,798
Total amount of fees paid to insurance companyUSD $15,479
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
Welfare Benefit Premiums Paid to CarrierUSD $209,766
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,798
Amount paid for insurance broker fees10319
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )
Policy contract number2KA8
Policy instance 1
Insurance contract or identification number2KA8
Number of Individuals Covered338
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,363
Total amount of fees paid to insurance companyUSD $119,604
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,036,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,363
Amount paid for insurance broker fees119604
Additional information about fees paid to insurance brokerPERSISTENCY BONUS, PRODUCER SERVICE FEE
Insurance broker organization code?3
CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )
Policy contract number2KA8
Policy instance 1
Insurance contract or identification number2KA8
Number of Individuals Covered304
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,149
Total amount of fees paid to insurance companyUSD $135,529
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,868,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $629
Amount paid for insurance broker fees93218
Additional information about fees paid to insurance brokerNEW BUSINESS & PERSISTENCY BONUS, PRODUCER SERVICE FEE
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberG000AW7Z
Policy instance 2
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered206
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340706
Policy instance 2
Insurance contract or identification number3340706
Number of Individuals Covered163
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,865
Total amount of fees paid to insurance companyUSD $50,179
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,515,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,865
Amount paid for insurance broker fees50179
Additional information about fees paid to insurance brokerBENEFIT ADVISOR PAYMENTS
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberG000AW7Z
Policy instance 1
Insurance contract or identification numberG000AW7Z
Insurance policy start date2020-03-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 4
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered197
Insurance policy start date2019-03-01
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $3,657
Total amount of fees paid to insurance companyUSD $2,789
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 $43,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,657
Amount paid for insurance broker fees278
Additional information about fees paid to insurance brokerAGENT OR BROKER ON RECORD
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 3
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered197
Insurance policy start date2019-03-01
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $4,521
Total amount of fees paid to insurance companyUSD $3,317
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 $52,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,521
Amount paid for insurance broker fees3317
Additional information about fees paid to insurance brokerAGENT OR BROKER ON RECORD
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 2
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered197
Insurance policy start date2019-03-01
Insurance policy end date2020-03-01
Total amount of commissions paid to insurance brokerUSD $3,484
Total amount of fees paid to insurance companyUSD $2,478
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
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 $39,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,484
Amount paid for insurance broker fees2478
Additional information about fees paid to insurance brokerAGENT OF BROKER OF RECORD
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340706
Policy instance 1
Insurance contract or identification number3340706
Number of Individuals Covered165
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,145
Total amount of fees paid to insurance companyUSD $53,366
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 BenefitYes
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 $1,601,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,145
Amount paid for insurance broker fees53366
Additional information about fees paid to insurance brokerBENEFIT ADVISOR PAYMENTS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 2
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered193
Insurance policy start date2018-03-01
Insurance policy end date2019-03-01
Total amount of commissions paid to insurance brokerUSD $4,522
Total amount of fees paid to insurance companyUSD $2,469
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 $52,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,522
Amount paid for insurance broker fees2469
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD / OTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 3
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered193
Insurance policy start date2018-03-01
Insurance policy end date2019-03-01
Total amount of commissions paid to insurance brokerUSD $3,449
Total amount of fees paid to insurance companyUSD $1,862
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
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 $38,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,449
Amount paid for insurance broker fees1862
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD / OTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 4
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered193
Insurance policy start date2018-03-01
Insurance policy end date2019-03-01
Total amount of commissions paid to insurance brokerUSD $3,690
Total amount of fees paid to insurance companyUSD $2,067
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 $43,800
Commission paid to Insurance BrokerUSD $3,690
Amount paid for insurance broker fees2067
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD / OTHER COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340706
Policy instance 1
Insurance contract or identification number3340706
Number of Individuals Covered155
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,711
Total amount of fees paid to insurance companyUSD $48,371
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 $1,469,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,711
Amount paid for insurance broker fees48371
Additional information about fees paid to insurance brokerBENEFIT ADVISOR PAYMENTS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AW7Z
Policy instance 3
Insurance contract or identification numberG000AW7Z
Number of Individuals Covered189
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $10,695
Total amount of fees paid to insurance companyUSD $11,629
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
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00474412
Policy instance 2
Insurance contract or identification number00474412
Number of Individuals Covered150
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $8,329
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 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
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3340706
Policy instance 1
Insurance contract or identification number3340706
Number of Individuals Covered161
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $100
Total amount of fees paid to insurance companyUSD $65,145
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
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No

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