DPS, INC. has sponsored the creation of one or more 401k plans.
Additional information about DPS, INC.
Submission information for form 5500 for 401k plan DPS, INC. HEALTH & WELFARE PLAN
401k plan membership statisitcs for DPS, INC. HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2019 : DPS, INC. HEALTH & WELFARE PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total transfer of assets to this plan | 2019-12-31 | $76,013 |
| Total transfer of assets to this plan | 2019-12-31 | $76,013 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $67,482 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $67,482 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $139,131 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $139,131 |
| Total income from all sources (including contributions) | 2019-12-31 | $1,062,178 |
| Total income from all sources (including contributions) | 2019-12-31 | $1,062,178 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total of all expenses incurred | 2019-12-31 | $1,113,752 |
| Total of all expenses incurred | 2019-12-31 | $1,113,752 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $975,341 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $975,341 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $1,062,178 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $1,062,178 |
| Value of total assets at end of year | 2019-12-31 | $163,416 |
| Value of total assets at end of year | 2019-12-31 | $163,416 |
| Value of total assets at beginning of year | 2019-12-31 | $210,626 |
| Value of total assets at beginning of year | 2019-12-31 | $210,626 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $138,411 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $138,411 |
| Total interest from all sources | 2019-12-31 | $0 |
| Total interest from all sources | 2019-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | Yes |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | Yes |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2019-12-31 | $0 |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2019-12-31 | $0 |
| Administrative expenses professional fees incurred | 2019-12-31 | $27,563 |
| Administrative expenses professional fees incurred | 2019-12-31 | $27,563 |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $25,000 |
| Value of fidelity bond cover | 2019-12-31 | $25,000 |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $8,795 |
| Contributions received from participants | 2019-12-31 | $8,795 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $96,228 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $96,228 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $9,281 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $9,281 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $50,031 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $50,031 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $27,829 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $27,829 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $6,327 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $6,327 |
| Administrative expenses (other) incurred | 2019-12-31 | $23,993 |
| Administrative expenses (other) incurred | 2019-12-31 | $23,993 |
| Liabilities. Value of operating payables at end of year | 2019-12-31 | $6,677 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $74,937 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $74,937 |
| Total non interest bearing cash at end of year | 2019-12-31 | $149,700 |
| Total non interest bearing cash at end of year | 2019-12-31 | $149,700 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $634 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $634 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $-51,574 |
| Value of net income/loss | 2019-12-31 | $-51,574 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $95,934 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $95,934 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $71,495 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $71,495 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $307,976 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $307,976 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $1,053,383 |
| Contributions received in cash from employer | 2019-12-31 | $1,053,383 |
| Employer contributions (assets) at end of year | 2019-12-31 | $4,435 |
| Employer contributions (assets) at end of year | 2019-12-31 | $4,435 |
| Employer contributions (assets) at beginning of year | 2019-12-31 | $159,961 |
| Employer contributions (assets) at beginning of year | 2019-12-31 | $159,961 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $571,137 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $571,137 |
| Contract administrator fees | 2019-12-31 | $86,855 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $32,976 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $32,976 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $57,867 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $57,867 |
| Did the plan have assets held for investment | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Accountancy firm name | 2019-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm name | 2019-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2019-12-31 | 410746749 |
| Accountancy firm EIN | 2019-12-31 | 410746749 |
| 2015 : DPS, INC. HEALTH & WELFARE PLAN 2015 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $138,736 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $0 |
| Total income from all sources (including contributions) | 2015-12-31 | $835,065 |
| Total of all expenses incurred | 2015-12-31 | $888,134 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $740,552 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $835,065 |
| Value of total assets at end of year | 2015-12-31 | $85,667 |
| Value of total assets at beginning of year | 2015-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $147,582 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Administrative expenses professional fees incurred | 2015-12-31 | $10,750 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $200,000 |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Administrative expenses (other) incurred | 2015-12-31 | $34,107 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $63,074 |
| Liabilities. Value of operating payables at beginning of year | 2015-12-31 | $0 |
| Total non interest bearing cash at end of year | 2015-12-31 | $75,205 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $0 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-53,069 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $-53,069 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $198,193 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $835,065 |
| Employer contributions (assets) at end of year | 2015-12-31 | $10,462 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $0 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $542,359 |
| Contract administrator fees | 2015-12-31 | $102,725 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2015-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2015-12-31 | $75,662 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-12-31 | $0 |
| Did the plan have assets held for investment | 2015-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | GALLINA LLP |
| Accountancy firm EIN | 2015-12-31 | 942147510 |
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: N/A ) |
| Policy contract number | FCE0-001 |
| Policy instance | 7 |
| Insurance contract or identification number | FCE0-001 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | 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 $962 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 08994 |
| Policy instance | 6 |
| Insurance contract or identification number | 08994 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $11,373 | | Total amount of fees paid to insurance company | USD $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 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $227,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,373 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 207978 |
| Policy instance | 5 |
| Insurance contract or identification number | VAR 207978 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $246 | | Total amount of fees paid to insurance company | USD $223 | | 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 | No | | 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 $2,232 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $246 | | Amount paid for insurance broker fees | 223 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 159069 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 159069 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,440 | | Total amount of fees paid to insurance company | USD $1,309 | | 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 | | 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 $13,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,440 | | Amount paid for insurance broker fees | 1309 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 11273-55 |
| Policy instance | 3 |
| Insurance contract or identification number | 11273-55 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
| Policy contract number | CLLMBDPS5 |
| Policy instance | 2 |
| Insurance contract or identification number | CLLMBDPS5 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $135 | | Total amount of fees paid to insurance company | USD $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 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $5,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $135 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBDPS5 |
| Policy instance | 1 |
| Insurance contract or identification number | CLLMBDPS5 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $679 | | Total amount of fees paid to insurance company | USD $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 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 | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $23,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $679 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | PD-337, PD-347 |
| Policy instance | 3 |
| Insurance contract or identification number | PD-337, PD-347 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $26 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 681703 |
| Policy instance | 2 |
| Insurance contract or identification number | VAR 681703 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $215 | | Total amount of fees paid to insurance company | USD $195 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,952 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $215 | | Amount paid for insurance broker fees | 195 | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 681455 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 681455 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $1,259 | | Total amount of fees paid to insurance company | USD $1,144 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,259 | | Amount paid for insurance broker fees | 1144 | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC. |
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