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HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 401k Plan overview

Plan NameHOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN
Plan identification number 502

HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Other welfare benefit cover

401k Sponsoring company profile

HOSPITAL SAN CARLOS BORROMEO has sponsored the creation of one or more 401k plans.

Company Name:HOSPITAL SAN CARLOS BORROMEO
Employer identification number (EIN):660371418
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-02-01
5022021-05-01
5022020-05-01
5022019-05-01
5022018-05-01
5022017-05-01MIGDALIA ORTIZ
5022016-05-01MIGDALIA ORTIZ
5022015-05-01MIGDALIA ORTIZ
5022014-05-01MIGDALIA ORTIZ
5022013-05-01MIGDALIA ORTIZ
5022012-05-01MIGDALIA ORTIZ MIGDALIA ORTIZ2013-07-30
5022011-05-01MIGDALIA ORTIZ
5022010-05-01MIGDALIA ORTIZ

Plan Statistics for HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN

401k plan membership statisitcs for HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN

Measure Date Value
2022: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01318
Total number of active participants reported on line 7a of the Form 55002022-02-01255
Total of all active and inactive participants2022-02-01255
Total participants2022-02-01255
2021: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01318
Total number of active participants reported on line 7a of the Form 55002021-05-01318
Total of all active and inactive participants2021-05-01318
Total participants2021-05-01318
2020: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01301
Total number of active participants reported on line 7a of the Form 55002020-05-01318
Total of all active and inactive participants2020-05-01318
Total participants2020-05-01318
2019: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01263
Total number of active participants reported on line 7a of the Form 55002019-05-01301
Total of all active and inactive participants2019-05-01301
Total participants2019-05-01301
2018: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01262
Total number of active participants reported on line 7a of the Form 55002018-05-01263
Total of all active and inactive participants2018-05-01263
Total participants2018-05-01263
2017: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01262
Total number of active participants reported on line 7a of the Form 55002017-05-01262
Total of all active and inactive participants2017-05-01262
Total participants2017-05-01262
2016: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01298
Total number of active participants reported on line 7a of the Form 55002016-05-01262
Total of all active and inactive participants2016-05-01262
Total participants2016-05-01262
2015: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01326
Total number of active participants reported on line 7a of the Form 55002015-05-01298
Total of all active and inactive participants2015-05-01298
Total participants2015-05-01298
2014: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01325
Total number of active participants reported on line 7a of the Form 55002014-05-01326
Total of all active and inactive participants2014-05-01326
Total participants2014-05-01326
2013: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01325
Total number of active participants reported on line 7a of the Form 55002013-05-01325
Total of all active and inactive participants2013-05-01325
Total participants2013-05-01325
2012: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01320
Total number of active participants reported on line 7a of the Form 55002012-05-01325
Total of all active and inactive participants2012-05-01325
Total participants2012-05-01325
2011: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01300
Total number of active participants reported on line 7a of the Form 55002011-05-01320
Total of all active and inactive participants2011-05-01320
Total participants2011-05-01320
2010: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01301
Total number of active participants reported on line 7a of the Form 55002010-05-01300
Total of all active and inactive participants2010-05-01300
Total participants2010-05-01300

Form 5500 Responses for HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN

2022: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Submission has been amendedNo
2021-05-01This submission is the final filingNo
2021-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-05-01Plan is a collectively bargained planNo
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – InsuranceYes
2020: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedNo
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – InsuranceYes
2019: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Submission has been amendedNo
2019-05-01This submission is the final filingNo
2019-05-01This return/report is a short plan year return/report (less than 12 months)No
2019-05-01Plan is a collectively bargained planNo
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – InsuranceYes
2018: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Submission has been amendedNo
2018-05-01This submission is the final filingNo
2018-05-01This return/report is a short plan year return/report (less than 12 months)No
2018-05-01Plan is a collectively bargained planNo
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – InsuranceYes
2017: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Submission has been amendedNo
2017-05-01This submission is the final filingNo
2017-05-01This return/report is a short plan year return/report (less than 12 months)No
2017-05-01Plan is a collectively bargained planNo
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – InsuranceYes
2016: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – InsuranceYes
2015: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Submission has been amendedNo
2015-05-01This submission is the final filingNo
2015-05-01This return/report is a short plan year return/report (less than 12 months)No
2015-05-01Plan is a collectively bargained planNo
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – InsuranceYes
2014: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedNo
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)No
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – InsuranceYes
2013: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – InsuranceYes
2012: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Submission has been amendedNo
2011-05-01This submission is the final filingNo
2011-05-01This return/report is a short plan year return/report (less than 12 months)No
2011-05-01Plan is a collectively bargained planNo
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2010: HOSPITAL SAN CARLOS BORROMEO BASIC LIFE & AD&D PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Submission has been amendedNo
2010-05-01This submission is the final filingNo
2010-05-01This return/report is a short plan year return/report (less than 12 months)No
2010-05-01Plan is a collectively bargained planNo
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )
Policy contract number1-5033-000
Policy instance 1
Insurance contract or identification number1-5033-000
Number of Individuals Covered255
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $857
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $857
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )
Policy contract number1-5033-000
Policy instance 1
Insurance contract or identification number1-5033-000
Number of Individuals Covered318
Insurance policy start date2021-05-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $643
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $643
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )
Policy contract number1-5033-000
Policy instance 1
Insurance contract or identification number1-5033-000
Number of Individuals Covered318
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $873
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $873
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )
Policy contract number1-5033-000
Policy instance 1
Insurance contract or identification number1-5033-000
Number of Individuals Covered301
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $894
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $894
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
MULTINATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 72087 )
Policy contract number72087
Policy instance 1
Insurance contract or identification number72087
Number of Individuals Covered263
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $889
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $889
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069G
Policy instance 1
Insurance contract or identification number869069G
Number of Individuals Covered262
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,307
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,307
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameIKON BENEFITS GROUP, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069G
Policy instance 1
Insurance contract or identification number869069G
Number of Individuals Covered298
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $1,486
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,486
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameIKON BENEFITS GROUP, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069G
Policy instance 1
Insurance contract or identification number869069G
Number of Individuals Covered326
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $1,502
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,502
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameIKON BENEFITS GROUP, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069G
Policy instance 1
Insurance contract or identification number869069G
Number of Individuals Covered325
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $1,482
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,482
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameIKON BENEFITS GROUP, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069-0GL
Policy instance 1
Insurance contract or identification number869069-0GL
Number of Individuals Covered325
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,326
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,326
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameIKON INSURANCE, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number8690369G
Policy instance 1
Insurance contract or identification number8690369G
Number of Individuals Covered320
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $1,193
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number869069G
Policy instance 1
Insurance contract or identification number869069G
Number of Individuals Covered300
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $1,266
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNIVERSAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60041 )
Policy contract numberGL/ADD0605-0066
Policy instance 2
Insurance contract or identification numberGL/ADD0605-0066
Number of Individuals Covered301
Insurance policy start date2009-05-01
Insurance policy end date2010-04-30
Total amount of commissions paid to insurance brokerUSD $1,368
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNIVERSAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60041 )
Policy contract numberGL/ADD0605-0066
Policy instance 3
Insurance contract or identification numberGL/ADD0605-0066
Number of Individuals Covered326
Insurance policy start date2008-05-01
Insurance policy end date2009-04-30
Total amount of commissions paid to insurance brokerUSD $1,634
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNIVERSAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60041 )
Policy contract numberGL/ADD0605-0066
Policy instance 4
Insurance contract or identification numberGL/ADD0605-0066
Number of Individuals Covered354
Insurance policy start date2007-05-01
Insurance policy end date2008-04-30
Total amount of commissions paid to insurance brokerUSD $1,684
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNIVERSAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60041 )
Policy contract numberGL/ADD0605-0066
Policy instance 5
Insurance contract or identification numberGL/ADD0605-0066
Number of Individuals Covered363
Insurance policy start date2006-05-01
Insurance policy end date2007-04-30
Total amount of commissions paid to insurance brokerUSD $1,693
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SECUROS DE VIDA TRIPLE-S INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberV-0505002
Policy instance 6
Insurance contract or identification numberV-0505002
Number of Individuals Covered334
Insurance policy start date2005-05-01
Insurance policy end date2006-04-30
Total amount of commissions paid to insurance brokerUSD $1,296
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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