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BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 401k Plan overview

Plan NameBOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN
Plan identification number 504

BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

BOWL AMERICA INCORPORATED has sponsored the creation of one or more 401k plans.

Company Name:BOWL AMERICA INCORPORATED
Employer identification number (EIN):540646173
NAIC Classification:713900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042018-11-01CHERYL DRAGOO2020-02-07
5042017-11-01CHERYL A. DRAGOO2019-05-09
5042016-11-01CHERYL A DRAGOO CHERYL A DRAGOO2018-03-12
5042015-11-01CHERYL A DRAGOO
5042014-11-01CHERYL DRAGOO
5042013-11-01CHERYL A DRAGOO
5042012-11-01CHERYL A DRAGOO CHERYL A DRAGOO2014-05-28
5042011-11-01CHERYL A DRAGOO CHERYL A DRAGOO2013-09-30
5042010-11-01BRAD YOUNG
5042009-11-01BRAD YOUNG
5042008-11-01BRAD YOUNG

Plan Statistics for BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN

401k plan membership statisitcs for BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN

Measure Date Value
2018: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-11-0169
Total number of active participants reported on line 7a of the Form 55002018-11-0169
Number of retired or separated participants receiving benefits2018-11-010
Number of other retired or separated participants entitled to future benefits2018-11-010
Total of all active and inactive participants2018-11-0169
Number of employers contributing to the scheme2018-11-010
2017: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01111
Total number of active participants reported on line 7a of the Form 55002017-11-01111
Number of retired or separated participants receiving benefits2017-11-010
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01111
Number of employers contributing to the scheme2017-11-010
2016: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01137
Total number of active participants reported on line 7a of the Form 55002016-11-01119
Number of retired or separated participants receiving benefits2016-11-010
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01119
2015: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01137
Total number of active participants reported on line 7a of the Form 55002015-11-01137
Number of retired or separated participants receiving benefits2015-11-010
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01137
2014: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01140
Total number of active participants reported on line 7a of the Form 55002014-11-01137
Number of retired or separated participants receiving benefits2014-11-010
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01137
2013: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2013 401k membership
Total participants, beginning-of-year2013-11-01140
Total number of active participants reported on line 7a of the Form 55002013-11-01132
Number of retired or separated participants receiving benefits2013-11-010
Number of other retired or separated participants entitled to future benefits2013-11-010
Total of all active and inactive participants2013-11-01132
2012: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2012 401k membership
Total participants, beginning-of-year2012-11-01153
Total number of active participants reported on line 7a of the Form 55002012-11-01140
Number of retired or separated participants receiving benefits2012-11-010
Number of other retired or separated participants entitled to future benefits2012-11-010
Total of all active and inactive participants2012-11-01140
2011: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01250
Total number of active participants reported on line 7a of the Form 55002011-11-01257
Number of retired or separated participants receiving benefits2011-11-010
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01257
2010: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2010 401k membership
Total participants, beginning-of-year2010-11-01244
Total number of active participants reported on line 7a of the Form 55002010-11-01214
Total of all active and inactive participants2010-11-01214
Total participants2010-11-01214
2009: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2009 401k membership
Total participants, beginning-of-year2009-11-01257
Total number of active participants reported on line 7a of the Form 55002009-11-01244
Total of all active and inactive participants2009-11-01244
Total participants2009-11-01244
2008: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2008 401k membership
Total participants, beginning-of-year2008-11-01256
Total number of active participants reported on line 7a of the Form 55002008-11-01257
Total of all active and inactive participants2008-11-01257
Total participants2008-11-01257

Form 5500 Responses for BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN

2018: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2018 form 5500 responses
2018-11-01Type of plan entitySingle employer plan
2018-11-01Plan funding arrangement – InsuranceYes
2018-11-01Plan benefit arrangement – InsuranceYes
2017: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – InsuranceYes
2016: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – InsuranceYes
2015: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – InsuranceYes
2014: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01Submission has been amendedNo
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – InsuranceYes
2013: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2013 form 5500 responses
2013-11-01Type of plan entitySingle employer plan
2013-11-01Submission has been amendedNo
2013-11-01This submission is the final filingNo
2013-11-01This return/report is a short plan year return/report (less than 12 months)No
2013-11-01Plan is a collectively bargained planNo
2013-11-01Plan funding arrangement – InsuranceYes
2013-11-01Plan benefit arrangement – InsuranceYes
2012: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2012 form 5500 responses
2012-11-01Type of plan entitySingle employer plan
2012-11-01Submission has been amendedNo
2012-11-01This submission is the final filingNo
2012-11-01This return/report is a short plan year return/report (less than 12 months)No
2012-11-01Plan is a collectively bargained planNo
2012-11-01Plan funding arrangement – InsuranceYes
2012-11-01Plan benefit arrangement – InsuranceYes
2011: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedYes
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)No
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – InsuranceYes
2010: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2010 form 5500 responses
2010-11-01Type of plan entitySingle employer plan
2010-11-01First time form 5500 has been submittedYes
2010-11-01Submission has been amendedNo
2010-11-01This submission is the final filingNo
2010-11-01This return/report is a short plan year return/report (less than 12 months)No
2010-11-01Plan is a collectively bargained planNo
2010-11-01Plan funding arrangement – InsuranceYes
2010-11-01Plan benefit arrangement – InsuranceYes
2009: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2009 form 5500 responses
2009-11-01Type of plan entitySingle employer plan
2009-11-01First time form 5500 has been submittedYes
2009-11-01Submission has been amendedNo
2009-11-01This submission is the final filingNo
2009-11-01This return/report is a short plan year return/report (less than 12 months)No
2009-11-01Plan is a collectively bargained planNo
2009-11-01Plan funding arrangement – InsuranceYes
2009-11-01Plan benefit arrangement – InsuranceYes
2008: BOWL AMERICA EMPLOYEE HOSPITALIZATION AND DENTAL PLAN 2008 form 5500 responses
2008-11-01Type of plan entitySingle employer plan
2008-11-01First time form 5500 has been submittedYes
2008-11-01Submission has been amendedNo
2008-11-01This submission is the final filingNo
2008-11-01This return/report is a short plan year return/report (less than 12 months)No
2008-11-01Plan is a collectively bargained planNo
2008-11-01Plan funding arrangement – InsuranceYes
2008-11-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927
Policy instance 1
Insurance contract or identification number21927
Number of Individuals Covered102
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $29,970
Total amount of fees paid to insurance companyUSD $4,790
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $559,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,970
Amount paid for insurance broker fees4790
Additional information about fees paid to insurance brokerBONUS NON-MONETARY COMPENSATION
Insurance broker organization code?3
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5470278
Policy instance 2
Insurance contract or identification number5470278
Number of Individuals Covered56
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $2,873
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,873
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5470278
Policy instance 2
Insurance contract or identification number5470278
Number of Individuals Covered52
Insurance policy start date2017-11-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $599
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927 (MA)
Policy instance 1
Insurance contract or identification number21927 (MA)
Number of Individuals Covered111
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $31,860
Total amount of fees paid to insurance companyUSD $8,363
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $592,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5470278
Policy instance 1
Insurance contract or identification number5470278
Number of Individuals Covered56
Insurance policy start date2015-11-01
Insurance policy end date2016-10-31
Total amount of commissions paid to insurance brokerUSD $3,213
Total amount of fees paid to insurance companyUSD $17
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,213
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927
Policy instance 2
Insurance contract or identification number21927
Number of Individuals Covered134
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $34,379
Total amount of fees paid to insurance companyUSD $1,350
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $679,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,379
Amount paid for insurance broker fees1350
Additional information about fees paid to insurance brokerANNUAL BOB
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927
Policy instance 2
Insurance contract or identification number21927
Number of Individuals Covered147
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $30,080
Total amount of fees paid to insurance companyUSD $1,500
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $765,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,080
Amount paid for insurance broker fees1500
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5470278
Policy instance 1
Insurance contract or identification number5470278
Number of Individuals Covered68
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $3,717
Total amount of fees paid to insurance companyUSD $34
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,717
Amount paid for insurance broker fees34
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
CITIZENS SECURITY (National Association of Insurance Commissioners NAIC id number: 61921 )
Policy contract number20126
Policy instance 2
Insurance contract or identification number20126
Number of Individuals Covered73
Insurance policy start date2013-11-01
Insurance policy end date2014-02-01
Total amount of commissions paid to insurance brokerUSD $977
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $977
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5470278
Policy instance 3
Insurance contract or identification number5470278
Number of Individuals Covered72
Insurance policy start date2014-02-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $3,023
Total amount of fees paid to insurance companyUSD $34
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $30,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,023
Amount paid for insurance broker fees34
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927
Policy instance 1
Insurance contract or identification number21927
Number of Individuals Covered132
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $27,413
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $675,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,413
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
CITIZENS SECURITY (National Association of Insurance Commissioners NAIC id number: 61921 )
Policy contract number20126
Policy instance 1
Insurance contract or identification number20126
Number of Individuals Covered79
Insurance policy start date2012-11-01
Insurance policy end date2013-10-31
Total amount of commissions paid to insurance brokerUSD $4,439
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $44,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,439
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP LLC
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number21927
Policy instance 2
Insurance contract or identification number21927
Number of Individuals Covered151
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $30,310
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $764,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,272
Insurance broker organization code?3
Insurance broker nameSTEVEN G COSBY
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 47060 )
Policy contract number877939 HNOSHORT
Policy instance 1
Insurance contract or identification number877939 HNOSHORT
Number of Individuals Covered202
Insurance policy start date2012-01-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $2,494
Total amount of fees paid to insurance companyUSD $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 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
Welfare Benefit Premiums Paid to CarrierUSD $97,657
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: 0000 )
Policy contract number877939
Policy instance 2
Insurance contract or identification number877939
Number of Individuals Covered204
Insurance policy start date2011-11-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $4,927
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $167,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CITIZENS SECURITY (National Association of Insurance Commissioners NAIC id number: 61921 )
Policy contract number20126
Policy instance 3
Insurance contract or identification number20126
Number of Individuals Covered86
Insurance policy start date2011-11-01
Insurance policy end date2012-10-31
Total amount of commissions paid to insurance brokerUSD $4,616
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA INC. (National Association of Insurance Commissioners NAIC id number: )
Policy contract numberUS412781
Policy instance 1
Insurance contract or identification numberUS412781
Number of Individuals Covered190
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $32,467
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,082,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CITIZENS SECURITY (National Association of Insurance Commissioners NAIC id number: 61921 )
Policy contract number20126
Policy instance 2
Insurance contract or identification number20126
Number of Individuals Covered89
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $5,094
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number713014
Policy instance 1
Insurance contract or identification number713014
Number of Individuals Covered220
Insurance policy start date2008-11-01
Insurance policy end date2009-10-31
Total amount of commissions paid to insurance brokerUSD $31,052
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,035,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CITIZENS SECURITY (National Association of Insurance Commissioners NAIC id number: 61921 )
Policy contract number20126
Policy instance 2
Insurance contract or identification number20126
Number of Individuals Covered102
Insurance policy start date2008-11-01
Insurance policy end date2009-10-21
Total amount of commissions paid to insurance brokerUSD $4,519
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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