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VALLEYSTAR HEALTH & WELFARE PLAN 401k Plan overview

Plan NameVALLEYSTAR HEALTH & WELFARE PLAN
Plan identification number 510

VALLEYSTAR HEALTH & WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

VALLEYSTAR CREDIT UNION has sponsored the creation of one or more 401k plans.

Company Name:VALLEYSTAR CREDIT UNION
Employer identification number (EIN):546040482
NAIC Classification:522130
NAIC Description:Credit Unions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VALLEYSTAR HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5102022-05-01
5102021-05-01
5102020-05-01
5102019-05-01

Plan Statistics for VALLEYSTAR HEALTH & WELFARE PLAN

401k plan membership statisitcs for VALLEYSTAR HEALTH & WELFARE PLAN

Measure Date Value
2022: VALLEYSTAR HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-05-01132
Total number of active participants reported on line 7a of the Form 55002022-05-01148
Number of retired or separated participants receiving benefits2022-05-011
Number of other retired or separated participants entitled to future benefits2022-05-015
Total of all active and inactive participants2022-05-01154
2021: VALLEYSTAR HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01137
Total number of active participants reported on line 7a of the Form 55002021-05-01131
Number of retired or separated participants receiving benefits2021-05-016
Number of other retired or separated participants entitled to future benefits2021-05-0112
Total of all active and inactive participants2021-05-01149
2020: VALLEYSTAR HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01140
Total number of active participants reported on line 7a of the Form 55002020-05-01145
Number of retired or separated participants receiving benefits2020-05-0112
Number of other retired or separated participants entitled to future benefits2020-05-019
Total of all active and inactive participants2020-05-01166
2019: VALLEYSTAR HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01121
Total number of active participants reported on line 7a of the Form 55002019-05-01144
Number of retired or separated participants receiving benefits2019-05-011
Number of other retired or separated participants entitled to future benefits2019-05-017
Total of all active and inactive participants2019-05-01152

Form 5500 Responses for VALLEYSTAR HEALTH & WELFARE PLAN

2022: VALLEYSTAR HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-05-01Type of plan entitySingle employer plan
2022-05-01Submission has been amendedNo
2022-05-01This submission is the final filingNo
2022-05-01This return/report is a short plan year return/report (less than 12 months)No
2022-05-01Plan is a collectively bargained planNo
2022-05-01Plan funding arrangement – InsuranceYes
2022-05-01Plan benefit arrangement – InsuranceYes
2021: VALLEYSTAR HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Submission has been amendedNo
2021-05-01This submission is the final filingNo
2021-05-01This return/report is a short plan year return/report (less than 12 months)No
2021-05-01Plan is a collectively bargained planNo
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – InsuranceYes
2020: VALLEYSTAR HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedNo
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan funding arrangement – General assets of the sponsorYes
2020-05-01Plan benefit arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – General assets of the sponsorYes
2019: VALLEYSTAR HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01First time form 5500 has been submittedYes
2019-05-01Submission has been amendedNo
2019-05-01This submission is the final filingNo
2019-05-01This return/report is a short plan year return/report (less than 12 months)No
2019-05-01Plan is a collectively bargained planNo
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0C4CR
Policy instance 5
Insurance contract or identification numberGVTL0C4CR
Number of Individuals Covered61
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $1,732
Total amount of fees paid to insurance companyUSD $1,890
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLIFE & AD&D VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,732
Amount paid for insurance broker fees1390
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0C4CR
Policy instance 4
Insurance contract or identification numberGLUG0C4CR
Number of Individuals Covered154
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $2,086
Total amount of fees paid to insurance companyUSD $1,921
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $20,856
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,086
Amount paid for insurance broker fees921
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30066784
Policy instance 3
Insurance contract or identification number30066784
Number of Individuals Covered137
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $1,211
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,211
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0C4CR
Policy instance 2
Insurance contract or identification numberGLTD0C4CR
Number of Individuals Covered148
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $2,470
Total amount of fees paid to insurance companyUSD $2,092
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,470
Amount paid for insurance broker fees1092
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number0A3F3Z
Policy instance 1
Insurance contract or identification number0A3F3Z
Number of Individuals Covered266
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $44,429
Total amount of fees paid to insurance companyUSD $1,314
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,871,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,429
Amount paid for insurance broker fees1314
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30066784
Policy instance 3
Insurance contract or identification number30066784
Number of Individuals Covered127
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $1,169
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,169
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00560818
Policy instance 2
Insurance contract or identification number00560818
Number of Individuals Covered135
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $17,033
Total amount of fees paid to insurance companyUSD $4,272
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, OPTIONAL AD&D, OPTIONAL LIFE
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 $78,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,810
Amount paid for insurance broker fees4272
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number0A3F3Z
Policy instance 1
Insurance contract or identification number0A3F3Z
Number of Individuals Covered241
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $37,135
Total amount of fees paid to insurance companyUSD $3,247
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,585,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,135
Amount paid for insurance broker fees3247
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30066784
Policy instance 3
Insurance contract or identification number30066784
Number of Individuals Covered126
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,121
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,121
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00560818
Policy instance 2
Insurance contract or identification number00560818
Number of Individuals Covered139
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $7,831
Total amount of fees paid to insurance companyUSD $3,907
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, OPTIONAL AD&D, OPTIONAL LIFE
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 $78,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,831
Amount paid for insurance broker fees3907
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number0A3F3Z
Policy instance 1
Insurance contract or identification number0A3F3Z
Number of Individuals Covered250
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $34,002
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,362,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,002
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number30066784
Policy instance 3
Insurance contract or identification number30066784
Number of Individuals Covered125
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00560818
Policy instance 2
Insurance contract or identification number00560818
Number of Individuals Covered144
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $16,848
Total amount of fees paid to insurance companyUSD $5,884
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, OPTIONAL AD&D, OPTIONAL LIFE
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 $168,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,848
Amount paid for insurance broker fees5884
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number0A3F3Z
Policy instance 1
Insurance contract or identification number0A3F3Z
Number of Individuals Covered212
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $29,000
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,605,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,000
Insurance broker organization code?3

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