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M3 USA CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan NameM3 USA CORPORATION WELFARE BENEFIT PLAN
Plan identification number 501

M3 USA CORPORATION WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

M3 USA CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:M3 USA CORPORATION
Employer identification number (EIN):710955864
NAIC Classification:541519
NAIC Description:Other Computer Related Services

Additional information about M3 USA CORPORATION

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 3720726

More information about M3 USA CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan M3 USA CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-05-01MARINA LAMITINA2023-12-18
5012021-05-01MARINA LAMITINA2022-11-20
5012020-05-01MARINA LAMITINA2021-11-15
5012019-05-01MARINA LAMITINA2020-11-19
5012018-05-01MARINA LAMITINA2020-02-05
5012017-05-01
5012016-05-01NEAL SAMADDAR
5012015-05-01SOUGATA SAMADDAR
5012014-05-01NEAL SAMADDAR

Plan Statistics for M3 USA CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for M3 USA CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2022: M3 USA CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-05-01389
Total number of active participants reported on line 7a of the Form 55002022-05-01410
Number of retired or separated participants receiving benefits2022-05-0111
Number of other retired or separated participants entitled to future benefits2022-05-01129
Total of all active and inactive participants2022-05-01550
2021: M3 USA CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01302
Total number of active participants reported on line 7a of the Form 55002021-05-01313
Number of retired or separated participants receiving benefits2021-05-013
Number of other retired or separated participants entitled to future benefits2021-05-0173
Total of all active and inactive participants2021-05-01389
2020: M3 USA CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01301
Total number of active participants reported on line 7a of the Form 55002020-05-01299
Number of retired or separated participants receiving benefits2020-05-013
Number of other retired or separated participants entitled to future benefits2020-05-010
Total of all active and inactive participants2020-05-01302
2019: M3 USA CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01279
Total number of active participants reported on line 7a of the Form 55002019-05-01299
Number of retired or separated participants receiving benefits2019-05-012
Number of other retired or separated participants entitled to future benefits2019-05-010
Total of all active and inactive participants2019-05-01301
2018: M3 USA CORPORATION WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01257
Total number of active participants reported on line 7a of the Form 55002018-05-01278
Number of retired or separated participants receiving benefits2018-05-011
Number of other retired or separated participants entitled to future benefits2018-05-010
Total of all active and inactive participants2018-05-01279
Number of employers contributing to the scheme2018-05-010
2017: M3 USA CORPORATION WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01193
Total number of active participants reported on line 7a of the Form 55002017-05-01257
Number of retired or separated participants receiving benefits2017-05-011
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-01258
Number of employers contributing to the scheme2017-05-010
2016: M3 USA CORPORATION WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01241
Total number of active participants reported on line 7a of the Form 55002016-05-01189
Number of retired or separated participants receiving benefits2016-05-014
Number of other retired or separated participants entitled to future benefits2016-05-010
Total of all active and inactive participants2016-05-01193
2015: M3 USA CORPORATION WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01138
Total number of active participants reported on line 7a of the Form 55002015-05-01241
Number of retired or separated participants receiving benefits2015-05-0113
Number of other retired or separated participants entitled to future benefits2015-05-010
Total of all active and inactive participants2015-05-01254
2014: M3 USA CORPORATION WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01113
Total number of active participants reported on line 7a of the Form 55002014-05-01138
Number of retired or separated participants receiving benefits2014-05-012
Number of other retired or separated participants entitled to future benefits2014-05-010
Total of all active and inactive participants2014-05-01140

Form 5500 Responses for M3 USA CORPORATION WELFARE BENEFIT PLAN

2022: M3 USA CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-05-01Type of plan entitySingle employer plan
2022-05-01Submission has been amendedNo
2022-05-01This submission is the final filingNo
2022-05-01This return/report is a short plan year return/report (less than 12 months)No
2022-05-01Plan is a collectively bargained planNo
2022-05-01Plan funding arrangement – InsuranceYes
2022-05-01Plan funding arrangement – General assets of the sponsorYes
2022-05-01Plan benefit arrangement – InsuranceYes
2022-05-01Plan benefit arrangement – General assets of the sponsorYes
2021: M3 USA CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Submission has been amendedNo
2021-05-01This submission is the final filingNo
2021-05-01This return/report is a short plan year return/report (less than 12 months)No
2021-05-01Plan is a collectively bargained planNo
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan funding arrangement – General assets of the sponsorYes
2021-05-01Plan benefit arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – General assets of the sponsorYes
2020: M3 USA CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedNo
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan funding arrangement – General assets of the sponsorYes
2020-05-01Plan benefit arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – General assets of the sponsorYes
2019: M3 USA CORPORATION WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – General assets of the sponsorYes
2018: M3 USA CORPORATION WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan funding arrangement – General assets of the sponsorYes
2018-05-01Plan benefit arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – General assets of the sponsorYes
2017: M3 USA CORPORATION WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan funding arrangement – General assets of the sponsorYes
2017-05-01Plan benefit arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – General assets of the sponsorYes
2016: M3 USA CORPORATION WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes
2015: M3 USA CORPORATION WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2015-05-01Plan benefit arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – General assets of the sponsorYes
2014: M3 USA CORPORATION WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01First time form 5500 has been submittedYes
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 funding arrangement – General assets of the sponsorYes
2014-05-01Plan benefit arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 3
Insurance contract or identification number30047935
Number of Individuals Covered351
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $2,034
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,034
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD0605152
Policy instance 2
Insurance contract or identification numberSGD0605152
Number of Individuals Covered410
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $21,647
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $263,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,647
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3345007
Policy instance 1
Insurance contract or identification number3345007
Number of Individuals Covered694
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $444
Total amount of fees paid to insurance companyUSD $5
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $12,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $444
Insurance broker organization code?3
Amount paid for insurance broker fees5
Additional information about fees paid to insurance brokerSERVICE GEN.AGENT FEES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 3
Insurance contract or identification number30047935
Number of Individuals Covered268
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $1,324
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,324
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605152
Policy instance 2
Insurance contract or identification numberSGD605152
Number of Individuals Covered313
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $18,676
Total amount of fees paid to insurance companyUSD $2,995
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $186,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,676
Amount paid for insurance broker fees2995
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0618810
Policy instance 1
Insurance contract or identification number0618810
Number of Individuals Covered263
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $6,550
Total amount of fees paid to insurance companyUSD $-71
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $165,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,550
Amount paid for insurance broker fees-71
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 3
Insurance contract or identification number30047935
Number of Individuals Covered246
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,423
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,296
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,423
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605152
Policy instance 2
Insurance contract or identification numberSGD605152
Number of Individuals Covered299
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $16,177
Total amount of fees paid to insurance companyUSD $2,617
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $166,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,177
Amount paid for insurance broker fees2617
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0618810
Policy instance 1
Insurance contract or identification number0618810
Number of Individuals Covered249
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $6,207
Total amount of fees paid to insurance companyUSD $619
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $156,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,207
Amount paid for insurance broker fees619
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 3
Insurance contract or identification number30047935
Number of Individuals Covered244
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $1,243
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,208
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,243
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK603462
Policy instance 2
Insurance contract or identification numberSOK603462
Number of Individuals Covered299
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $12,317
Total amount of fees paid to insurance companyUSD $2,426
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 $123,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,317
Amount paid for insurance broker fees2426
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0618810
Policy instance 1
Insurance contract or identification number0618810
Number of Individuals Covered250
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $6,674
Total amount of fees paid to insurance companyUSD $1,078
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare 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 $168,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,674
Insurance broker organization code?3
Amount paid for insurance broker fees1078
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605074
Policy instance 3
Insurance contract or identification numberSGM605074
Number of Individuals Covered278
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $12,833
Total amount of fees paid to insurance companyUSD $2,375
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $128,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $12,833
Amount paid for insurance broker fees2375
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 2
Insurance contract or identification number30047935
Number of Individuals Covered238
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $1,268
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,268
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618810
Policy instance 1
Insurance contract or identification number618810
Number of Individuals Covered247
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $6,355
Total amount of fees paid to insurance companyUSD $1,362
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $160,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,355
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605074
Policy instance 3
Insurance contract or identification numberSGM605074
Number of Individuals Covered257
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $13,233
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $132,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $13,233
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30047935
Policy instance 2
Insurance contract or identification number30047935
Number of Individuals Covered219
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,233
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,233
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number618810
Policy instance 1
Insurance contract or identification number618810
Number of Individuals Covered233
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $6,053
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $152,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,053
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCORPORATE SYNERGIES GROUP, LLC

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