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PAVEMENT SERVICES HEALTH AND WELFARE PLAN 401k Plan overview

Plan NamePAVEMENT SERVICES HEALTH AND WELFARE PLAN
Plan identification number 502

PAVEMENT SERVICES HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Other welfare benefit cover

401k Sponsoring company profile

PAVEMENT SERVICES CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:PAVEMENT SERVICES CORPORATION
Employer identification number (EIN):751897613
NAIC Classification:238900

Additional information about PAVEMENT SERVICES CORPORATION

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 1983-02-24
Company Identification Number: 0064452600
Legal Registered Office Address: PO BOX 1107

EULESS
United States of America (USA)
76039

More information about PAVEMENT SERVICES CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PAVEMENT SERVICES HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-10-01
5022020-10-01
5022019-10-01
5022018-10-01
5022017-10-01
5022016-10-01NADINE GIVENS
5022015-10-01NADINE GIVENS
5022008-10-01NADINE GIVENS

Plan Statistics for PAVEMENT SERVICES HEALTH AND WELFARE PLAN

401k plan membership statisitcs for PAVEMENT SERVICES HEALTH AND WELFARE PLAN

Measure Date Value
2022: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01134
Total number of active participants reported on line 7a of the Form 55002022-01-01135
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01135
2021: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01128
Total number of active participants reported on line 7a of the Form 55002021-10-01134
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01134
2020: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01152
Total number of active participants reported on line 7a of the Form 55002020-10-01128
Number of retired or separated participants receiving benefits2020-10-010
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01128
2019: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01149
Total number of active participants reported on line 7a of the Form 55002019-10-01152
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01152
2018: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01160
Total number of active participants reported on line 7a of the Form 55002018-10-01148
Number of retired or separated participants receiving benefits2018-10-011
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-01149
2017: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01143
Total number of active participants reported on line 7a of the Form 55002017-10-01160
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01160
2016: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01122
Total number of active participants reported on line 7a of the Form 55002016-10-01143
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01143
2015: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01117
Total number of active participants reported on line 7a of the Form 55002015-10-01122
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01122
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-10-010
Total participants2015-10-01122
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2015-10-010
2008: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year2008-10-0140
Total number of active participants reported on line 7a of the Form 55002008-10-0134
Number of retired or separated participants receiving benefits2008-10-012
Number of other retired or separated participants entitled to future benefits2008-10-010
Total of all active and inactive participants2008-10-0136
Total participants2008-10-0136

Form 5500 Responses for PAVEMENT SERVICES HEALTH AND WELFARE PLAN

2022: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Submission has been amendedNo
2021-10-01This submission is the final filingNo
2021-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-10-01Plan is a collectively bargained planNo
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – General assets of the sponsorYes
2020: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Submission has been amendedNo
2020-10-01This submission is the final filingNo
2020-10-01This return/report is a short plan year return/report (less than 12 months)No
2020-10-01Plan is a collectively bargained planNo
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Submission has been amendedNo
2019-10-01This submission is the final filingNo
2019-10-01This return/report is a short plan year return/report (less than 12 months)No
2019-10-01Plan is a collectively bargained planNo
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Submission has been amendedNo
2018-10-01This submission is the final filingNo
2018-10-01This return/report is a short plan year return/report (less than 12 months)No
2018-10-01Plan is a collectively bargained planNo
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – General assets of the sponsorYes
2017: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Submission has been amendedNo
2017-10-01This submission is the final filingNo
2017-10-01This return/report is a short plan year return/report (less than 12 months)No
2017-10-01Plan is a collectively bargained planNo
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – General assets of the sponsorYes
2016: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01First time form 5500 has been submittedYes
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2008: PAVEMENT SERVICES HEALTH AND WELFARE PLAN 2008 form 5500 responses
2008-10-01Type of plan entitySingle employer plan
2008-10-01Submission has been amendedNo
2008-10-01This submission is the final filingNo
2008-10-01This return/report is a short plan year return/report (less than 12 months)No
2008-10-01Plan is a collectively bargained planNo
2008-10-01Plan funding arrangement – InsuranceYes
2008-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered135
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,749
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $15,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,749
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered134
Insurance policy start date2021-10-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $231
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $3,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $231
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number906248
Policy instance 2
Insurance contract or identification number906248
Number of Individuals Covered129
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $40,806
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
Welfare Benefit Premiums Paid to CarrierUSD $775,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees40806
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered128
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $693
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $17,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $693
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number906248
Policy instance 2
Insurance contract or identification number906248
Number of Individuals Covered145
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $46,733
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
Welfare Benefit Premiums Paid to CarrierUSD $902,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees35674
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered152
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $2,709
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $16,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,709
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number906248
Policy instance 2
Insurance contract or identification number906248
Number of Individuals Covered140
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $44,835
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
Welfare Benefit Premiums Paid to CarrierUSD $775,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees44835
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered148
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $2,793
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $16,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,793
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number906248
Policy instance 2
Insurance contract or identification number906248
Number of Individuals Covered168
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $33,625
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
Welfare Benefit Premiums Paid to CarrierUSD $678,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered160
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $2,243
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $16,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0906248
Policy instance 2
Insurance contract or identification number0906248
Number of Individuals Covered120
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $23,795
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 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
Welfare Benefit Premiums Paid to CarrierUSD $497,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,795
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWORTHAM-FORT WORTH, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number304382
Policy instance 1
Insurance contract or identification number304382
Number of Individuals Covered122
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $1,522
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 providedACCIDENTAL DEATH & DISMEMBERMENT, VOLUNTARY LIFE, AND VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
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 $11,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,522
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameWORTHAM-FORT WORTH, INC.

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