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CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 401k Plan overview

Plan NameCAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN
Plan identification number 503

CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

PINNACLE ARCHITECTURAL LIGHTING has sponsored the creation of one or more 401k plans.

Company Name:PINNACLE ARCHITECTURAL LIGHTING
Employer identification number (EIN):770602906
NAIC Classification:339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032019-01-01
5032019-01-01
5032018-01-01MARK GUMINSKI
5032017-12-01MARK GUMINSKI
5032016-12-01MARK GUMINSKI
5032015-12-01MARK GUMINSKI
5032015-12-01
5032014-12-01MARK GUMINSKI
5032013-12-01MARK GUMINSKI

Plan Statistics for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN

401k plan membership statisitcs for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN

Measure Date Value
2019: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01286
Total number of active participants reported on line 7a of the Form 55002019-01-01374
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01375
2018: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01231
Total number of active participants reported on line 7a of the Form 55002018-01-01286
Number of retired or separated participants receiving benefits2018-01-012
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01288
2017: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01231
Total number of active participants reported on line 7a of the Form 55002017-12-01231
Number of retired or separated participants receiving benefits2017-12-015
Number of other retired or separated participants entitled to future benefits2017-12-010
Total of all active and inactive participants2017-12-01236
2016: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2016 401k membership
Total participants, beginning-of-year2016-12-01304
Total number of active participants reported on line 7a of the Form 55002016-12-01231
Number of retired or separated participants receiving benefits2016-12-015
Number of other retired or separated participants entitled to future benefits2016-12-010
Total of all active and inactive participants2016-12-01236
2015: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2015 401k membership
Total participants, beginning-of-year2015-12-01248
Total number of active participants reported on line 7a of the Form 55002015-12-01304
Number of retired or separated participants receiving benefits2015-12-012
Number of other retired or separated participants entitled to future benefits2015-12-010
Total of all active and inactive participants2015-12-01306
2014: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2014 401k membership
Total participants, beginning-of-year2014-12-01173
Total number of active participants reported on line 7a of the Form 55002014-12-01248
Number of retired or separated participants receiving benefits2014-12-011
Number of other retired or separated participants entitled to future benefits2014-12-010
Total of all active and inactive participants2014-12-01249
2013: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2013 401k membership
Total participants, beginning-of-year2013-12-01105
Total number of active participants reported on line 7a of the Form 55002013-12-01126
Number of retired or separated participants receiving benefits2013-12-010
Number of other retired or separated participants entitled to future benefits2013-12-010
Total of all active and inactive participants2013-12-01126

Form 5500 Responses for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN

2019: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01Submission has been amendedNo
2017-12-01This submission is the final filingNo
2017-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-12-01Plan is a collectively bargained planNo
2017-12-01Plan funding arrangement – InsuranceYes
2017-12-01Plan funding arrangement – General assets of the sponsorYes
2017-12-01Plan benefit arrangement – InsuranceYes
2017-12-01Plan benefit arrangement – General assets of the sponsorYes
2016: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2016 form 5500 responses
2016-12-01Type of plan entitySingle employer plan
2016-12-01Submission has been amendedNo
2016-12-01This submission is the final filingNo
2016-12-01This return/report is a short plan year return/report (less than 12 months)No
2016-12-01Plan is a collectively bargained planNo
2016-12-01Plan funding arrangement – InsuranceYes
2016-12-01Plan funding arrangement – General assets of the sponsorYes
2016-12-01Plan benefit arrangement – InsuranceYes
2016-12-01Plan benefit arrangement – General assets of the sponsorYes
2015: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2015 form 5500 responses
2015-12-01Type of plan entitySingle employer plan
2015-12-01Submission has been amendedYes
2015-12-01This submission is the final filingNo
2015-12-01This return/report is a short plan year return/report (less than 12 months)No
2015-12-01Plan is a collectively bargained planNo
2015-12-01Plan funding arrangement – InsuranceYes
2015-12-01Plan funding arrangement – General assets of the sponsorYes
2015-12-01Plan benefit arrangement – InsuranceYes
2015-12-01Plan benefit arrangement – General assets of the sponsorYes
2014: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2014 form 5500 responses
2014-12-01Type of plan entitySingle employer plan
2014-12-01First time form 5500 has been submittedYes
2014-12-01Submission has been amendedNo
2014-12-01This submission is the final filingNo
2014-12-01This return/report is a short plan year return/report (less than 12 months)No
2014-12-01Plan is a collectively bargained planNo
2014-12-01Plan funding arrangement – InsuranceYes
2014-12-01Plan funding arrangement – General assets of the sponsorYes
2014-12-01Plan benefit arrangement – InsuranceYes
2014-12-01Plan benefit arrangement – General assets of the sponsorYes
2013: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN 2013 form 5500 responses
2013-12-01Type of plan entitySingle employer plan
2013-12-01First time form 5500 has been submittedYes
2013-12-01Submission has been amendedNo
2013-12-01This submission is the final filingNo
2013-12-01This return/report is a short plan year return/report (less than 12 months)No
2013-12-01Plan is a collectively bargained planNo
2013-12-01Plan funding arrangement – InsuranceYes
2013-12-01Plan funding arrangement – General assets of the sponsorYes
2013-12-01Plan benefit arrangement – InsuranceYes
2013-12-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0ATVH
Policy instance 7
Insurance contract or identification numberGUC0ATVH
Number of Individuals Covered108
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,896
Total amount of fees paid to insurance companyUSD $1,860
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 BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $39,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,896
Amount paid for insurance broker fees1860
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009188
Policy instance 1
Insurance contract or identification number000009188
Number of Individuals Covered144
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $10,812
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 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,723
Insurance broker organization code?3
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009187
Policy instance 2
Insurance contract or identification number000009187
Number of Individuals Covered13
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $347
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 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $347
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATVH
Policy instance 3
Insurance contract or identification numberGLUG0ATVH
Number of Individuals Covered264
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,107
Total amount of fees paid to insurance companyUSD $374
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
Welfare Benefit Premiums Paid to CarrierUSD $7,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,107
Amount paid for insurance broker fees374
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ATVH
Policy instance 4
Insurance contract or identification numberGLTD0ATVH
Number of Individuals Covered264
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,227
Total amount of fees paid to insurance companyUSD $1,064
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $21,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,227
Amount paid for insurance broker fees1064
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00623715
Policy instance 5
Insurance contract or identification number00623715
Number of Individuals Covered163
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $33,199
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 BenefitYes
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 $249,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,199
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ATVH
Policy instance 6
Insurance contract or identification numberGVTL0ATVH
Number of Individuals Covered86
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,258
Total amount of fees paid to insurance companyUSD $1,026
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D
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 $21,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,258
Amount paid for insurance broker fees1026
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0ATVH
Policy instance 7
Insurance contract or identification numberGUC0ATVH
Number of Individuals Covered108
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,842
Total amount of fees paid to insurance companyUSD $807
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 BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $38,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,842
Amount paid for insurance broker fees807
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ATVH
Policy instance 6
Insurance contract or identification numberGVTL0ATVH
Number of Individuals Covered91
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,229
Total amount of fees paid to insurance companyUSD $475
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D
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 $21,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,229
Amount paid for insurance broker fees475
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )
Policy contract number195810
Policy instance 5
Insurance contract or identification number195810
Number of Individuals Covered183
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $13,100
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 BenefitYes
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 $88,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,100
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ATVH
Policy instance 4
Insurance contract or identification numberGLTD0ATVH
Number of Individuals Covered286
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,345
Total amount of fees paid to insurance companyUSD $500
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $22,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,345
Amount paid for insurance broker fees500
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATVH
Policy instance 3
Insurance contract or identification numberGLUG0ATVH
Number of Individuals Covered286
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,168
Total amount of fees paid to insurance companyUSD $170
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
Welfare Benefit Premiums Paid to CarrierUSD $7,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,168
Amount paid for insurance broker fees170
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009187
Policy instance 2
Insurance contract or identification number000009187
Number of Individuals Covered22
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $452
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $452
Insurance broker organization code?3
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009188
Policy instance 1
Insurance contract or identification number000009188
Number of Individuals Covered148
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $10,987
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,848
Insurance broker organization code?3
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009187
Policy instance 2
Insurance contract or identification number000009187
Number of Individuals Covered16
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $37
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 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 $358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATVH
Policy instance 3
Insurance contract or identification numberGLUG0ATVH
Number of Individuals Covered231
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $89
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 providedAD&D
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 $595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $89
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ATVH
Policy instance 4
Insurance contract or identification numberGLTD0ATVH
Number of Individuals Covered231
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $259
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $1,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $259
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 )
Policy contract number195810
Policy instance 5
Insurance contract or identification number195810
Number of Individuals Covered165
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $92
Total amount of fees paid to insurance companyUSD $313
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 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 $23,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $92
Amount paid for insurance broker fees313
Additional information about fees paid to insurance brokerBROKER FEES
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ATVH
Policy instance 6
Insurance contract or identification numberGVTL0ATVH
Number of Individuals Covered92
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $250
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE & AD&D
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 $1,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $250
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0ATVH
Policy instance 7
Insurance contract or identification numberGUC0ATVH
Number of Individuals Covered84
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $418
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 BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $418
Insurance broker organization code?3
Insurance broker nameCOBIZ INSURANCE
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number000009188
Policy instance 1
Insurance contract or identification number000009188
Number of Individuals Covered135
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $966
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $690
Insurance broker organization code?3
Insurance broker nameBETA HEALTH ASSOCIATION

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