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WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 401k Plan overview

Plan NameWELFARE HEALTH PLAN FOR SUPREME BEVERAGE
Plan identification number 501

WELFARE HEALTH PLAN FOR SUPREME BEVERAGE Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Vision
  • Temporary disability (accident and sickness)

401k Sponsoring company profile

SUPREME BEVERAGE COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name:SUPREME BEVERAGE COMPANY, INC.
Employer identification number (EIN):630459214
NAIC Classification:424800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WELFARE HEALTH PLAN FOR SUPREME BEVERAGE

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-01-01
5012019-01-01
5012018-01-01
5012018-01-01
5012017-03-01WILSON SHEPHERD

Plan Statistics for WELFARE HEALTH PLAN FOR SUPREME BEVERAGE

401k plan membership statisitcs for WELFARE HEALTH PLAN FOR SUPREME BEVERAGE

Measure Date Value
2020: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2020 401k membership
Total participants, beginning-of-year2020-01-01139
Total number of active participants reported on line 7a of the Form 55002020-01-01163
Total of all active and inactive participants2020-01-01163
Total participants2020-01-01163
2019: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2019 401k membership
Total participants, beginning-of-year2019-01-01130
Total number of active participants reported on line 7a of the Form 55002019-01-01139
Total of all active and inactive participants2019-01-01139
Total participants2019-01-01139
2018: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2018 401k membership
Total participants, beginning-of-year2018-01-01134
Total number of active participants reported on line 7a of the Form 55002018-01-01130
Total of all active and inactive participants2018-01-01130
Total participants2018-01-01130
2017: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2017 401k membership
Total participants, beginning-of-year2017-03-01150
Total number of active participants reported on line 7a of the Form 55002017-03-01133
Number of retired or separated participants receiving benefits2017-03-011
Total of all active and inactive participants2017-03-01134
Total participants2017-03-01134

Financial Data on WELFARE HEALTH PLAN FOR SUPREME BEVERAGE

Measure Date Value
2020 : WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$9,050
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$0
Total income from all sources (including contributions)2020-12-31$1,081,399
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$1,081,399
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$957,228
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,081,399
Value of total assets at end of year2020-12-31$9,050
Value of total assets at beginning of year2020-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$124,171
Total interest from all sources2020-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$40,000
If this is an individual account plan, was there a blackout period2020-12-31No
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$646,936
Participant contributions at end of year2020-12-31$9,050
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2020-12-31$13,835
Administrative expenses (other) incurred2020-12-31$13,254
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$0
Value of net assets at end of year (total assets less liabilities)2020-12-31$0
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$943,393
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$434,463
Contract administrator fees2020-12-31$110,917
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32020-12-31No
Liabilities. Value of benefit claims payable at end of year2020-12-31$9,050
Did the plan have assets held for investment2020-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Disclaimer
Accountancy firm name2020-12-31LUND ACCOUNTING, LLC
Accountancy firm EIN2020-12-31272258316
2019 : WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total income from all sources (including contributions)2019-12-31$1,049,836
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$1,049,836
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$861,354
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$1,049,836
Value of total assets at end of year2019-12-31$0
Value of total assets at beginning of year2019-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$188,482
Total interest from all sources2019-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Administrative expenses professional fees incurred2019-12-31$3,374
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$35,000
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$534,249
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2019-12-31$472,536
Administrative expenses (other) incurred2019-12-31$87,187
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$0
Value of net assets at end of year (total assets less liabilities)2019-12-31$0
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Investment advisory and management fees2019-12-31$13,210
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$388,818
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$515,587
Contract administrator fees2019-12-31$84,711
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-12-31No
Did the plan have assets held for investment2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31Yes
Opinion of an independent qualified public accountant for this plan2019-12-31Disclaimer
Accountancy firm name2019-12-31LUND ACCOUNTING, LLC
Accountancy firm EIN2019-12-31272258316
2018 : WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2018 401k financial data
Total unrealized appreciation/depreciation of assets2018-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$1,027
Total income from all sources (including contributions)2018-12-31$666,408
Total loss/gain on sale of assets2018-12-31$0
Total of all expenses incurred2018-12-31$676,615
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$581,519
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$666,408
Value of total assets at end of year2018-12-31$0
Value of total assets at beginning of year2018-12-31$11,234
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$95,096
Total interest from all sources2018-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2018-12-31$0
Administrative expenses professional fees incurred2018-12-31$2,302
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$35,000
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Contributions received from participants2018-12-31$666,408
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2018-12-31$129,540
Administrative expenses (other) incurred2018-12-31$47,949
Total non interest bearing cash at beginning of year2018-12-31$11,234
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$-10,207
Value of net assets at end of year (total assets less liabilities)2018-12-31$0
Value of net assets at beginning of year (total assets less liabilities)2018-12-31$10,207
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Investment advisory and management fees2018-12-31$3,296
Expenses. Payments to insurance carriers foe the provision of benefits2018-12-31$451,979
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contract administrator fees2018-12-31$41,549
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-12-31No
Liabilities. Value of benefit claims payable at beginning of year2018-12-31$1,027
Did the plan have assets held for investment2018-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31Yes
Opinion of an independent qualified public accountant for this plan2018-12-31Disclaimer
Accountancy firm name2018-12-31LUND ACCOUNTING, LLC
Accountancy firm EIN2018-12-31272258316
2017 : WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2017 401k financial data
Total unrealized appreciation/depreciation of assets2017-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$1,027
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$0
Total income from all sources (including contributions)2017-12-31$715,559
Total loss/gain on sale of assets2017-12-31$0
Total of all expenses incurred2017-12-31$705,352
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2017-12-31$410,891
Total contributions o plan (from employers,participants, others, non cash contrinutions)2017-12-31$715,559
Value of total assets at end of year2017-12-31$11,234
Value of total assets at beginning of year2017-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2017-12-31$294,461
Total interest from all sources2017-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2017-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31Yes
Value of fidelity bond cover2017-12-31$90,000
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Administrative expenses (other) incurred2017-12-31$294,461
Total non interest bearing cash at end of year2017-12-31$11,234
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net income/loss2017-12-31$10,207
Value of net assets at end of year (total assets less liabilities)2017-12-31$10,207
Value of net assets at beginning of year (total assets less liabilities)2017-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2017-12-31$410,891
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Contributions received in cash from employer2017-12-31$715,559
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-12-31No
Liabilities. Value of benefit claims payable at end of year2017-12-31$1,027
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2017-12-31Yes
Opinion of an independent qualified public accountant for this plan2017-12-31Disclaimer
Accountancy firm name2017-12-31LUND ACCOUNTING, LLC
Accountancy firm EIN2017-12-31272258316

Form 5500 Responses for WELFARE HEALTH PLAN FOR SUPREME BEVERAGE

2020: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: WELFARE HEALTH PLAN FOR SUPREME BEVERAGE 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Submission has been amendedNo
2017-03-01This submission is the final filingNo
2017-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-03-01Plan is a collectively bargained planNo
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AEA INCORPORATED CELL (National Association of Insurance Commissioners NAIC id number: 52512 )
Policy contract number10778-063
Policy instance 1
Insurance contract or identification number10778-063
Number of Individuals Covered163
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
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 number00456254
Policy instance 2
Insurance contract or identification number00456254
Number of Individuals Covered141
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,842
Total amount of fees paid to insurance companyUSD $2,993
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,421
Amount paid for insurance broker fees2993
AEA INCORPORATED CELL (National Association of Insurance Commissioners NAIC id number: 52512 )
Policy contract number10778-063
Policy instance 1
Insurance contract or identification number10778-063
Number of Individuals Covered139
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
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 number00456254
Policy instance 2
Insurance contract or identification number00456254
Number of Individuals Covered152
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $13,210
Total amount of fees paid to insurance companyUSD $2,769
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,605
Amount paid for insurance broker fees2769
Additional information about fees paid to insurance brokerFEES PAID
AMERICAN EMPLOYERS ALLIANCE, INC (National Association of Insurance Commissioners NAIC id number: 52512 )
Policy contract number10778-063
Policy instance 1
Insurance contract or identification number10778-063
Number of Individuals Covered130
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
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 number00456254
Policy instance 2
Insurance contract or identification number00456254
Number of Individuals Covered143
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $11,427
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,713
Additional information about fees paid to insurance brokerCOMMISSION
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00456254
Policy instance 1
Insurance contract or identification number00456254
Number of Individuals Covered130
Insurance policy start date2017-03-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 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 $44,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN EMPLOYERS ALLIANCE, INC (National Association of Insurance Commissioners NAIC id number: 52512 )
Policy contract number10778-063
Policy instance 2
Insurance contract or identification number10778-063
Number of Individuals Covered130
Insurance policy start date2017-03-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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