401k Plan data: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN plan

SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN
Plan identification number	505

SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SOUTHERN FURNITURE COMPANY OF CONOVER INC has sponsored the creation of one or more 401k plans.

Company Name: SOUTHERN FURNITURE COMPANY OF CONOVER INC

Employer identification number (EIN): 560612709

NAIC Classification: 337000

Additional information about SOUTHERN FURNITURE COMPANY OF CONOVER INC

Jurisdiction of Incorporation: North Carolina Secretary of State

Incorporation Date:

Company Identification Number: 0137314

More information about SOUTHERN FURNITURE COMPANY OF CONOVER INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2019-01-01
505 2018-01-01
505 2017-01-01 PATRICIA FLEMING
505 2016-01-01
505 2015-01-01
505 2011-01-01 JEROME BOLICK
505 2010-01-01 JEROME BOLICK
505 2009-01-01 PHIL WILSON

Plan Statistics for SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2019: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 5
Total of all active and inactive participants 2019-01-01 5
2018: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 150
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 133
Total of all active and inactive participants 2018-01-01 133
2017: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 150
Total of all active and inactive participants 2017-01-01 150
2016: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 127
Number of retired or separated participants receiving benefits 2016-01-01 1
Total of all active and inactive participants 2016-01-01 128
2015: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 130
Number of retired or separated participants receiving benefits 2015-01-01 1
Total of all active and inactive participants 2015-01-01 131
2011: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 95
Total of all active and inactive participants 2011-01-01 95
2010: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 186
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 109
Total of all active and inactive participants 2010-01-01 109
2009: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 247
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 186
Total of all active and inactive participants 2009-01-01 186

Measure	Date	Value
2019: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	5
Total of all active and inactive participants	2019-01-01	5
2018: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	150
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	133
Total of all active and inactive participants	2018-01-01	133
2017: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	150
Total of all active and inactive participants	2017-01-01	150
2016: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	127
Number of retired or separated participants receiving benefits	2016-01-01	1
Total of all active and inactive participants	2016-01-01	128
2015: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	130
Number of retired or separated participants receiving benefits	2015-01-01	1
Total of all active and inactive participants	2015-01-01	131
2011: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	95
Total of all active and inactive participants	2011-01-01	95
2010: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	186
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	109
Total of all active and inactive participants	2010-01-01	109
2009: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	247
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	186
Total of all active and inactive participants	2009-01-01	186

Financial Data on SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN

Measure	Date	Value
2010 : SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2010 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$11,429
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$98,001
Total income from all sources (including contributions)	2010-12-31	$661,181
Total of all expenses incurred	2010-12-31	$915,710
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$882,041
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$580,469
Value of total assets at end of year	2010-12-31	$11,429
Value of total assets at beginning of year	2010-12-31	$352,530
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$33,669
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$247,543
Participant contributions at beginning of year	2010-12-31	$25,757
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2010-12-31	$16,310
Other income not declared elsewhere	2010-12-31	$80,712
Administrative expenses (other) incurred	2010-12-31	$3,110
Total non interest bearing cash at end of year	2010-12-31	$11,429
Total non interest bearing cash at beginning of year	2010-12-31	$275,247
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$-254,529
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$254,529
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Expenses. Payments to insurance carriers foe the provision of benefits	2010-12-31	$198,687
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$332,926
Employer contributions (assets) at beginning of year	2010-12-31	$35,216
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$683,354
Contract administrator fees	2010-12-31	$30,559
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	2010-12-31	No
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$11,429
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$98,001
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	No
Opinion of an independent qualified public accountant for this plan	2010-12-31	Unqualified
Accountancy firm name	2010-12-31	DAVIDSON, HOLLAND, WHITESELL & CO.,
Accountancy firm EIN	2010-12-31	561706742

Form 5500 Responses for SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN

2019: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	Yes
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2011: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2010: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: SOUTHERN FURNITURE COMPANY OF CONOVER, INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	This submission is the final filing	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235091

Policy instance

Insurance contract or identification number	000010235091
Number of Individuals Covered	95
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $2,240
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,240
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0912760

Policy instance

Insurance contract or identification number	0912760
Number of Individuals Covered	85
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $42,124
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	42124
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235090

Policy instance

Insurance contract or identification number	000010235090
Number of Individuals Covered	32
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $2,940
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,940
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D033259

Policy instance

Insurance contract or identification number	00001D033259
Number of Individuals Covered	66
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $4,298
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,298
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235088

Policy instance

Insurance contract or identification number	000010235088
Number of Individuals Covered	96
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $1,250
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $6,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,250
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100023204

Policy instance

Insurance contract or identification number	40000100023204
Number of Individuals Covered	31
Insurance policy start date	2018-11-01
Insurance policy end date	2019-10-31
Total amount of commissions paid to insurance broker	USD $3,289
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $21,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,289
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

40000100023204

Policy instance

Insurance contract or identification number	40000100023204
Number of Individuals Covered	109
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $3,312
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $22,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,312
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

0912760

Policy instance

Insurance contract or identification number	0912760
Number of Individuals Covered	121
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $53,237
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	53237
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235090

Policy instance

Insurance contract or identification number	000010235090
Number of Individuals Covered	53
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $2,920
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

00001D033259

Policy instance

Insurance contract or identification number	00001D033259
Number of Individuals Covered	100
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $4,487
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,487
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235088

Policy instance

Insurance contract or identification number	000010235088
Number of Individuals Covered	133
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $1,254
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $6,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,254
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

000010235091

Policy instance

Insurance contract or identification number	000010235091
Number of Individuals Covered	133
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $2,221
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $14,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,221
Insurance broker organization code?	3

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50030169

Policy instance

Insurance contract or identification number	50030169
Number of Individuals Covered	127
Insurance policy start date	2017-07-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $5,569
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	A D & D
Welfare Benefit Premiums Paid to Carrier	USD $22,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,644
Insurance broker name	JUSTICE-CREWS INS AGENCY INC

AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )

Policy contract number

J4432Y

Policy instance

Insurance contract or identification number	J4432Y
Number of Individuals Covered	208
Insurance policy start date	2016-11-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $58,936
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,468
Insurance broker organization code?	3
Insurance broker name	MOSAIC GROUP SERVICES LLC

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

000978

Policy instance

Insurance contract or identification number	000978
Number of Individuals Covered	48
Insurance policy start date	2017-01-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $601
Total amount of fees paid to insurance company	USD $661
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,015
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	661
Additional information about fees paid to insurance broker	SERVICE FEE
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $601
Insurance broker name	JUSTICE-CREWS INS AGENCY INC

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

080975

Policy instance

Insurance contract or identification number	080975
Number of Individuals Covered	150
Insurance policy start date	2016-11-01
Insurance policy end date	2017-10-31
Total amount of commissions paid to insurance broker	USD $47,865
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,865
Insurance broker organization code?	3
Insurance broker name	WILLIAM J. CREWS

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

080975

Policy instance

Insurance contract or identification number	080975
Number of Individuals Covered	155
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $37,307
Total amount of fees paid to insurance company	USD $3,000
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,307
Amount paid for insurance broker fees	3000
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	WILLIAM J CREWS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10181657

Policy instance

Insurance contract or identification number	10181657
Number of Individuals Covered	129
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $3,080
Total amount of fees paid to insurance company	USD $440
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $15,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,080
Amount paid for insurance broker fees	440
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTIN-CREWS INS AGENCY INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10181655

Policy instance

Insurance contract or identification number	10181655
Number of Individuals Covered	129
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,566
Total amount of fees paid to insurance company	USD $222
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,566
Amount paid for insurance broker fees	222
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTIN-CREWS INS AGENCY INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

1D027062

Policy instance

Insurance contract or identification number	1D027062
Number of Individuals Covered	93
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $1,761
Total amount of fees paid to insurance company	USD $481
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,761
Amount paid for insurance broker fees	481
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTIN-CREWS INS AGENCY INC.

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

405004049

Policy instance

Insurance contract or identification number	405004049
Number of Individuals Covered	38
Insurance policy start date	2014-11-01
Insurance policy end date	2015-10-31
Total amount of commissions paid to insurance broker	USD $4,934
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $7,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,934
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	JUSTIN-CREWS INS AGENCY INC.

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001918

Policy instance

Insurance contract or identification number	50001918
Number of Individuals Covered	27
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $990
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

072959

Policy instance

Insurance contract or identification number	072959
Number of Individuals Covered	103
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $36,269
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001918

Policy instance

Insurance contract or identification number	50001918
Number of Individuals Covered	97
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $3,192
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )

Policy contract number

50001918

Policy instance

Insurance contract or identification number	50001918
Number of Individuals Covered	97
Insurance policy start date	2010-11-01
Insurance policy end date	2011-10-31
Total amount of commissions paid to insurance broker	USD $2,654
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 142441

Policy instance

Insurance contract or identification number	GL 142441
Number of Individuals Covered	129
Insurance policy start date	2010-06-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $7,509
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,509
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TENNESSEE

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 203948

Policy instance

Insurance contract or identification number	VAR 203948
Number of Individuals Covered	129
Insurance policy start date	2010-06-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $125
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $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 $125
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TENNESSEE

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 142441

Policy instance

Insurance contract or identification number	GL 142441
Number of Individuals Covered	147
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $11,461
Total amount of fees paid to insurance company	USD $278
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,461
Amount paid for insurance broker fees	278
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TENNESSEE

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

401834 0010

Policy instance

Insurance contract or identification number	401834 0010
Number of Individuals Covered	132
Insurance policy start date	2009-11-01
Insurance policy end date	2010-10-31
Total amount of commissions paid to insurance broker	USD $20,523
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $205,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,523
Insurance broker organization code?	3
Insurance broker name	PRIMARY PHYSICIAN CARE INC

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 203948

Policy instance

Insurance contract or identification number	VAR 203948
Number of Individuals Covered	147
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $346
Total amount of fees paid to insurance company	USD $8
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $346
Amount paid for insurance broker fees	8
Additional information about fees paid to insurance broker	ADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?	3
Insurance broker name	WILLIS OF TENNESSEE

Potentially related plans

SOUTHERN FURNITURE LEASING, INC 401(K) PLAN [EIN = 593720472]

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Company Name:	SOUTHERN FURNITURE COMPANY OF CONOVER INC
Employer identification number (EIN):	560612709
NAIC Classification:	337000

Jurisdiction of Incorporation:	North Carolina Secretary of State
Incorporation Date:
Company Identification Number:	0137314