BOWL AMERICA INCORPORATED has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BOWL AMERICA EMPLOYEE LIFE INSURANCE
| Measure | Date | Value |
|---|
| 2020: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 185 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 185 |
| 2019: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 202 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 202 |
| Number of employers contributing to the scheme | 2019-03-01 | 0 |
| 2018: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 216 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 216 |
| Number of employers contributing to the scheme | 2018-03-01 | 0 |
| 2017: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 221 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 221 |
| 2016: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 310 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 219 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 219 |
| 2015: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 334 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 310 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 310 |
| 2014: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 333 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 334 |
| Number of retired or separated participants receiving benefits | 2014-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-03-01 | 0 |
| Total of all active and inactive participants | 2014-03-01 | 334 |
| 2013: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 362 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 336 |
| Number of retired or separated participants receiving benefits | 2013-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-03-01 | 0 |
| Total of all active and inactive participants | 2013-03-01 | 336 |
| 2012: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 254 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 265 |
| Number of retired or separated participants receiving benefits | 2012-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-03-01 | 0 |
| Total of all active and inactive participants | 2012-03-01 | 265 |
| 2011: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 250 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 257 |
| Total of all active and inactive participants | 2011-03-01 | 257 |
| Total participants | 2011-03-01 | 257 |
| 2010: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-03-01 | 268 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-03-01 | 250 |
| Total of all active and inactive participants | 2010-03-01 | 250 |
| Total participants | 2010-03-01 | 250 |
| 2009: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 268 |
| Total of all active and inactive participants | 2009-03-01 | 268 |
| Total participants | 2009-03-01 | 268 |
| 2008: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-03-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-03-01 | 265 |
| Total of all active and inactive participants | 2008-03-01 | 265 |
| Total participants | 2008-03-01 | 265 |
| 2007: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-03-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-03-01 | 265 |
| Total of all active and inactive participants | 2007-03-01 | 265 |
| Total participants | 2007-03-01 | 265 |
| 2020: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Submission has been amended | No |
| 2020-03-01 | This submission is the final filing | No |
| 2020-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-03-01 | Plan is a collectively bargained plan | No |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | Submission has been amended | No |
| 2016-03-01 | This submission is the final filing | No |
| 2016-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-03-01 | Plan is a collectively bargained plan | No |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | No |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Submission has been amended | No |
| 2014-03-01 | This submission is the final filing | No |
| 2014-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-03-01 | Plan is a collectively bargained plan | No |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Submission has been amended | No |
| 2013-03-01 | This submission is the final filing | No |
| 2013-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-03-01 | Plan is a collectively bargained plan | No |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | Submission has been amended | No |
| 2012-03-01 | This submission is the final filing | No |
| 2012-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-03-01 | Plan is a collectively bargained plan | No |
| 2012-03-01 | Plan funding arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | First time form 5500 has been submitted | Yes |
| 2011-03-01 | Submission has been amended | No |
| 2011-03-01 | This submission is the final filing | No |
| 2011-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-03-01 | Plan is a collectively bargained plan | No |
| 2011-03-01 | Plan funding arrangement – Insurance | Yes |
| 2011-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2010 form 5500 responses |
|---|
| 2010-03-01 | Type of plan entity | Single employer plan |
| 2010-03-01 | First time form 5500 has been submitted | Yes |
| 2010-03-01 | Submission has been amended | No |
| 2010-03-01 | This submission is the final filing | No |
| 2010-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-03-01 | Plan is a collectively bargained plan | No |
| 2010-03-01 | Plan funding arrangement – Insurance | Yes |
| 2010-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | First time form 5500 has been submitted | Yes |
| 2009-03-01 | Submission has been amended | No |
| 2009-03-01 | This submission is the final filing | No |
| 2009-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-03-01 | Plan is a collectively bargained plan | No |
| 2009-03-01 | Plan funding arrangement – Insurance | Yes |
| 2009-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2008 form 5500 responses |
|---|
| 2008-03-01 | Type of plan entity | Single employer plan |
| 2008-03-01 | First time form 5500 has been submitted | Yes |
| 2008-03-01 | Submission has been amended | No |
| 2008-03-01 | This submission is the final filing | No |
| 2008-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-03-01 | Plan is a collectively bargained plan | No |
| 2008-03-01 | Plan funding arrangement – Insurance | Yes |
| 2008-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: BOWL AMERICA EMPLOYEE LIFE INSURANCE 2007 form 5500 responses |
|---|
| 2007-03-01 | Type of plan entity | Single employer plan |
| 2007-03-01 | First time form 5500 has been submitted | Yes |
| 2007-03-01 | Submission has been amended | No |
| 2007-03-01 | This submission is the final filing | No |
| 2007-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-03-01 | Plan is a collectively bargained plan | No |
| 2007-03-01 | Plan funding arrangement – Insurance | Yes |
| 2007-03-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 185 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $2,553 | | Total amount of fees paid to insurance company | USD $1,247 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,916 | | Amount paid for insurance broker fees | 1247 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 202 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $2,680 | | Total amount of fees paid to insurance company | USD $1,232 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,870 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $920 | | Amount paid for insurance broker fees | 1232 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 216 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $2,616 | | Total amount of fees paid to insurance company | USD $1,175 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,616 | | Amount paid for insurance broker fees | 1175 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 221 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $2,939 | | Total amount of fees paid to insurance company | USD $674 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $19,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $468 | | Amount paid for insurance broker fees | 674 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 310 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $2,994 | | Total amount of fees paid to insurance company | USD $709 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $19,962 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,994 | | Amount paid for insurance broker fees | 709 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 334 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $3,076 | | Total amount of fees paid to insurance company | USD $644 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $20,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,076 | | Amount paid for insurance broker fees | 644 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AKRC | | Number of Individuals Covered | 352 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,747 | | Total amount of fees paid to insurance company | USD $618 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $18,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,747 | | Amount paid for insurance broker fees | 618 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CORPORATE SYNERGIES GROUP, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AKRC |
| Policy instance | 1 |
| Insurance contract or identification number | G000AKRC | | Number of Individuals Covered | 365 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $2,922 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $19,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,171 | | Insurance broker organization code? | 3 | | Insurance broker name | STEVEN G. COSBY, INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 877939 |
| Policy instance | 1 |
| Insurance contract or identification number | 877939 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-01 | | Total amount of commissions paid to insurance broker | USD $2,046 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMSMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $18,536 | | 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 number | G000AKRC |
| Policy instance | 2 |
| Insurance contract or identification number | G000AKRC | | Number of Individuals Covered | 257 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-02-01 | | Total amount of commissions paid to insurance broker | USD $751 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMSMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,630 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 877939 |
| Policy instance | 1 |
| Insurance contract or identification number | 877939 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $2,349 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 877939 |
| Policy instance | 1 |
| Insurance contract or identification number | 877939 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $2,419 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $21,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 877939 |
| Policy instance | 1 |
| Insurance contract or identification number | 877939 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2007-03-01 | | Insurance policy end date | 2008-02-28 | | Total amount of commissions paid to insurance broker | USD $2,419 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
