401k Plan data: ACK CONTROLS, INC. WELFARE BENEFIT PLAN plan

ACK CONTROLS, INC. WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ACK CONTROLS, INC. WELFARE BENEFIT PLAN
Plan identification number	501

ACK CONTROLS, INC. WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CHUHATSU NORTH AMERICA, INC. has sponsored the creation of one or more 401k plans.

Company Name: CHUHATSU NORTH AMERICA, INC.

Employer identification number (EIN): 611384150

NAIC Classification: 332900

Additional information about CHUHATSU NORTH AMERICA, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2018-01-17

Company Identification Number: 0802913439

Legal Registered Office Address: 2600 HAPPY VALLEY RD

GLASGOW
United States of America (USA)
42141

More information about CHUHATSU NORTH AMERICA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ACK CONTROLS, INC. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KEVIN GOODMAN 2023-10-09
501 2021-01-01 KEVIN GOODMAN 2022-10-04
501 2020-01-01
501 2019-01-01
501 2018-01-01
501 2017-01-01 CARROLL KNICELY, JR. ROBERT MATTHEWS 2018-10-02
501 2016-01-01 CARROLL KNICELY, JR. ROBERT MATTHEWS 2017-06-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KEVIN GOODMAN	2023-10-09
501	2021-01-01	KEVIN GOODMAN	2022-10-04
501	2020-01-01
501	2019-01-01
501	2018-01-01
501	2017-01-01	CARROLL KNICELY, JR.		ROBERT MATTHEWS	2018-10-02
501	2016-01-01	CARROLL KNICELY, JR.		ROBERT MATTHEWS	2017-06-13

Plan Statistics for ACK CONTROLS, INC. WELFARE BENEFIT PLAN

401k plan membership statisitcs for ACK CONTROLS, INC. WELFARE BENEFIT PLAN

Measure Date Value
2022: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 106
Total of all active and inactive participants 2022-01-01 106
2021: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 147
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 107
Total of all active and inactive participants 2021-01-01 107
2020: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 177
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 147
Total of all active and inactive participants 2020-01-01 147
2019: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 297
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 177
Total of all active and inactive participants 2019-01-01 177
2018: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 246
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 297
Total of all active and inactive participants 2018-01-01 297
2017: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 274
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 246
Total of all active and inactive participants 2017-01-01 246
Total participants 2017-01-01 246
2016: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 287
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 274
Total of all active and inactive participants 2016-01-01 274
Total participants 2016-01-01 274

Measure	Date	Value
2022: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	106
Total of all active and inactive participants	2022-01-01	106
2021: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	147
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	107
Total of all active and inactive participants	2021-01-01	107
2020: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	177
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	147
Total of all active and inactive participants	2020-01-01	147
2019: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	297
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	177
Total of all active and inactive participants	2019-01-01	177
2018: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	297
Total of all active and inactive participants	2018-01-01	297
2017: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	246
Total of all active and inactive participants	2017-01-01	246
Total participants	2017-01-01	246
2016: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	287
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	274
Total of all active and inactive participants	2016-01-01	274
Total participants	2016-01-01	274

Form 5500 Responses for ACK CONTROLS, INC. WELFARE BENEFIT PLAN

2022: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: ACK CONTROLS, INC. WELFARE 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: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: ACK CONTROLS, INC. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: ACK CONTROLS, INC. WELFARE 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

Insurance Providers Used on plan

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	106
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,447
Total amount of fees paid to insurance company	USD $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
Commission paid to Insurance Broker	USD $1,447
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	105
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,487
Total amount of fees paid to insurance company	USD $773
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,487
Insurance broker organization code?	3
Amount paid for insurance broker fees	773
Additional information about fees paid to insurance broker	OVERRIDE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	75
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,129
Total amount of fees paid to insurance company	USD $710
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,129
Insurance broker organization code?	3
Amount paid for insurance broker fees	710
Additional information about fees paid to insurance broker	OVERRIDE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	106
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $519
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $5,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $519
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	106
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,384
Total amount of fees paid to insurance company	USD $1,331
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $43,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,384
Insurance broker organization code?	3
Amount paid for insurance broker fees	1331
Additional information about fees paid to insurance broker	OVERRIDE

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	107
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,460
Total amount of fees paid to insurance company	USD $1,468
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,404
Amount paid for insurance broker fees	1468
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	107
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $495
Total amount of fees paid to insurance company	USD $176
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $273
Amount paid for insurance broker fees	176
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	81
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,770
Total amount of fees paid to insurance company	USD $1,193
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,539
Amount paid for insurance broker fees	1193
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	107
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,329
Total amount of fees paid to insurance company	USD $1,105
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,187
Amount paid for insurance broker fees	1105
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	106
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,590
Total amount of fees paid to insurance company	USD $362
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
Commission paid to Insurance Broker	USD $877
Insurance broker organization code?	3
Amount paid for insurance broker fees	189
Additional information about fees paid to insurance broker	OVERRIDE

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	137
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,535
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $359,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,535

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

460244

Policy instance

Insurance contract or identification number	460244
Number of Individuals Covered	147
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of fees paid to insurance company	USD $958
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	958
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	147
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,866
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,866
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	147
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,411
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,411
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	147
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $410
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $4,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $410
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	147
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,307
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,307
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	177
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $43,773
Total amount of fees paid to insurance company	USD $2,363
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $390,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,773
Amount paid for insurance broker fees	2363
Additional information about fees paid to insurance broker	BONUS, OVERRIDE, NONMONETARY COMPENSATION
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

460244

Policy instance

Insurance contract or identification number	460244
Number of Individuals Covered	177
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,220
Total amount of fees paid to insurance company	USD $9,453
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,220
Amount paid for insurance broker fees	9453
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	174
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,111
Total amount of fees paid to insurance company	USD $902
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,111
Amount paid for insurance broker fees	902
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	142
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,264
Total amount of fees paid to insurance company	USD $941
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,264
Amount paid for insurance broker fees	941
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	174
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $710
Total amount of fees paid to insurance company	USD $163
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $710
Amount paid for insurance broker fees	163
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	174
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,854
Total amount of fees paid to insurance company	USD $1,222
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $58,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,854
Amount paid for insurance broker fees	1222
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	378
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $6,090
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,090
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	318
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $838
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $838
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	195
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,353
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,353
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	267
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,063
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,063
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

460244

Policy instance

Insurance contract or identification number	460244
Number of Individuals Covered	202
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,651
Total amount of fees paid to insurance company	USD $12,761
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,651
Amount paid for insurance broker fees	12761
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	203
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,548
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $436,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,548
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

00248601

Policy instance

Insurance contract or identification number	00248601
Number of Individuals Covered	246
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $212
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $461,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	212
Additional information about fees paid to insurance broker	BONUS, OVERRIDE
Insurance broker organization code?	3
Insurance broker name	BENEFIT INSURANCE MARKETING

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960951

Policy instance

Insurance contract or identification number	FLK960951
Number of Individuals Covered	242
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,366
Total amount of fees paid to insurance company	USD $1,707
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,366
Amount paid for insurance broker fees	1707
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	BENEFIT INSURANCE MARKETING

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLK960950

Policy instance

Insurance contract or identification number	FLK960950
Number of Individuals Covered	201
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,841
Total amount of fees paid to insurance company	USD $1,952
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,841
Amount paid for insurance broker fees	1952
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	BENEFIT INSURANCE MARKETING

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

OK969211

Policy instance

Insurance contract or identification number	OK969211
Number of Individuals Covered	242
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $908
Total amount of fees paid to insurance company	USD $341
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $908
Amount paid for insurance broker fees	341
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	BENEFIT INSURANCE MARKETING

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

FLX967701

Policy instance

Insurance contract or identification number	FLX967701
Number of Individuals Covered	242
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $6,037
Total amount of fees paid to insurance company	USD $2,260
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,037
Amount paid for insurance broker fees	2260
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	BENEFIT INSURANCE MARKETING

Potentially related plans

ACK CONTROLS, INC. WELFARE BENEFIT PLAN [EIN = 311282879]

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Company Name:	CHUHATSU NORTH AMERICA, INC.
Employer identification number (EIN):	611384150
NAIC Classification:	332900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2018-01-17
Company Identification Number:	0802913439
Legal Registered Office Address:	2600 HAPPY VALLEY RD GLASGOW United States of America (USA) 42141