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KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameKLOVER SEPA INC EMPLOYEE BENEFITS PLAN
Plan identification number 501

KLOVER SEPA INC EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

KLOVER SEPA INC. has sponsored the creation of one or more 401k plans.

Company Name:KLOVER SEPA INC.
Employer identification number (EIN):815335337
NAIC Classification:236200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KLOVER SEPA INC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-01-01
5012022-12-01
5012021-12-01
5012020-12-01
5012019-12-01DON MANTELL2021-04-06
5012018-12-01CHRISTA CLAYTON2020-03-16
5012017-12-01STACEY CONWAY2019-04-18

Plan Statistics for KLOVER SEPA INC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for KLOVER SEPA INC EMPLOYEE BENEFITS PLAN

Measure Date Value
2023: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2023 401k membership
Total participants, beginning-of-year2023-01-01162
Total number of active participants reported on line 7a of the Form 55002023-01-01137
Number of retired or separated participants receiving benefits2023-01-013
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01140
2022: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-12-01163
Total number of active participants reported on line 7a of the Form 55002022-12-01160
Number of retired or separated participants receiving benefits2022-12-012
Number of other retired or separated participants entitled to future benefits2022-12-010
Total of all active and inactive participants2022-12-01162
2021: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-12-01200
Total number of active participants reported on line 7a of the Form 55002021-12-01163
Number of retired or separated participants receiving benefits2021-12-012
Number of other retired or separated participants entitled to future benefits2021-12-010
Total of all active and inactive participants2021-12-01165
2020: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-12-01209
Total number of active participants reported on line 7a of the Form 55002020-12-01196
Number of retired or separated participants receiving benefits2020-12-014
Number of other retired or separated participants entitled to future benefits2020-12-010
Total of all active and inactive participants2020-12-01200
2019: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-12-01151
Total number of active participants reported on line 7a of the Form 55002019-12-01206
Number of retired or separated participants receiving benefits2019-12-013
Number of other retired or separated participants entitled to future benefits2019-12-010
Total of all active and inactive participants2019-12-01209
Number of employers contributing to the scheme2019-12-010
2018: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-12-01169
Total number of active participants reported on line 7a of the Form 55002018-12-01147
Number of retired or separated participants receiving benefits2018-12-014
Number of other retired or separated participants entitled to future benefits2018-12-010
Total of all active and inactive participants2018-12-01151
Number of employers contributing to the scheme2018-12-010
2017: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01129
Total number of active participants reported on line 7a of the Form 55002017-12-01169
Number of retired or separated participants receiving benefits2017-12-010
Number of other retired or separated participants entitled to future benefits2017-12-010
Total of all active and inactive participants2017-12-01169
Number of employers contributing to the scheme2017-12-010

Form 5500 Responses for KLOVER SEPA INC EMPLOYEE BENEFITS PLAN

2023: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Submission has been amendedNo
2023-01-01This submission is the final filingNo
2023-01-01This return/report is a short plan year return/report (less than 12 months)No
2023-01-01Plan is a collectively bargained planNo
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan funding arrangement – General assets of the sponsorYes
2023-01-01Plan benefit arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – General assets of the sponsorYes
2022: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-12-01Type of plan entitySingle employer plan
2022-12-01Submission has been amendedNo
2022-12-01This submission is the final filingNo
2022-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-12-01Plan is a collectively bargained planNo
2022-12-01Plan funding arrangement – InsuranceYes
2022-12-01Plan funding arrangement – General assets of the sponsorYes
2022-12-01Plan benefit arrangement – InsuranceYes
2022-12-01Plan benefit arrangement – General assets of the sponsorYes
2021: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-12-01Type of plan entitySingle employer plan
2021-12-01Submission has been amendedNo
2021-12-01This submission is the final filingNo
2021-12-01This return/report is a short plan year return/report (less than 12 months)No
2021-12-01Plan is a collectively bargained planNo
2021-12-01Plan funding arrangement – InsuranceYes
2021-12-01Plan funding arrangement – General assets of the sponsorYes
2021-12-01Plan benefit arrangement – InsuranceYes
2021-12-01Plan benefit arrangement – General assets of the sponsorYes
2020: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-12-01Type of plan entitySingle employer plan
2020-12-01Submission has been amendedNo
2020-12-01This submission is the final filingNo
2020-12-01This return/report is a short plan year return/report (less than 12 months)No
2020-12-01Plan is a collectively bargained planNo
2020-12-01Plan funding arrangement – InsuranceYes
2020-12-01Plan funding arrangement – General assets of the sponsorYes
2020-12-01Plan benefit arrangement – InsuranceYes
2020-12-01Plan benefit arrangement – General assets of the sponsorYes
2019: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-12-01Type of plan entitySingle employer plan
2019-12-01Plan funding arrangement – InsuranceYes
2019-12-01Plan funding arrangement – General assets of the sponsorYes
2019-12-01Plan benefit arrangement – InsuranceYes
2019-12-01Plan benefit arrangement – General assets of the sponsorYes
2018: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-12-01Type of plan entitySingle employer plan
2018-12-01Plan funding arrangement – InsuranceYes
2018-12-01Plan funding arrangement – General assets of the sponsorYes
2018-12-01Plan benefit arrangement – InsuranceYes
2018-12-01Plan benefit arrangement – General assets of the sponsorYes
2017: KLOVER SEPA INC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01First time form 5500 has been submittedYes
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

Insurance Providers Used on plan

AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract numberGAPPAGI-1028
Policy instance 2
Insurance contract or identification numberGAPPAGI-1028
Number of Individuals Covered120
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $36,930
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 providedGAP
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 $217,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00026976
Policy instance 1
Insurance contract or identification number00026976
Number of Individuals Covered137
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $12,610
Total amount of fees paid to insurance companyUSD $5,892
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $145,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number000
Policy instance 3
Insurance contract or identification number000
Number of Individuals Covered133
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 providedEAP
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 $3,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract numberGAPPAGI-1028
Policy instance 2
Insurance contract or identification numberGAPPAGI-1028
Number of Individuals Covered135
Insurance policy start date2022-12-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $11,261
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 providedGAP
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?Yes
Commission paid to Insurance BrokerUSD $6,625
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00026976
Policy instance 1
Insurance contract or identification number00026976
Number of Individuals Covered163
Insurance policy start date2022-12-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,003
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $13,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,003
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00026976
Policy instance 1
Insurance contract or identification number00026976
Number of Individuals Covered163
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $19,898
Total amount of fees paid to insurance companyUSD $688
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $184,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,898
Amount paid for insurance broker fees688
Additional information about fees paid to insurance brokerFEES, OVERRIDES
Insurance broker organization code?3
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract numberGAPPAGI-1028
Policy instance 2
Insurance contract or identification numberGAPPAGI-1028
Number of Individuals Covered135
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $40,765
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 providedGAP
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 $23,982
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered0
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 providedEAP
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?Yes
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered161
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 providedEAP
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 $1,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 )
Policy contract numberGP-PA0330
Policy instance 3
Insurance contract or identification numberGP-PA0330
Number of Individuals Covered166
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $65,842
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 providedGAP
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 $38,954
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10232604
Policy instance 2
Insurance contract or identification number10232604
Number of Individuals Covered196
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $7,501
Total amount of fees paid to insurance companyUSD $2,906
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 $45,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,501
Amount paid for insurance broker fees2906
Additional information about fees paid to insurance brokerFEES, OVERRIDES
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number617229
Policy instance 1
Insurance contract or identification number617229
Number of Individuals Covered177
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $8,577
Total amount of fees paid to insurance companyUSD $6,408
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $158,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,577
Amount paid for insurance broker fees1152
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSPL605756
Policy instance 6
Insurance contract or identification numberSPL605756
Number of Individuals Covered196
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $553
Total amount of fees paid to insurance companyUSD $345
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 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 $4,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $553
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGM607887
Policy instance 5
Insurance contract or identification numberSGM607887
Number of Individuals Covered196
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $2,726
Total amount of fees paid to insurance companyUSD $2,314
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
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 $33,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,726
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGM607887
Policy instance 5
Insurance contract or identification numberSGM607887
Number of Individuals Covered209
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $2,818
Total amount of fees paid to insurance companyUSD $2,049
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $29,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,818
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSALES AND SERVICE OVERRIDE
ACI SPECIALTY BENEFITS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered161
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $1,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 )
Policy contract numberGP-PA0330
Policy instance 3
Insurance contract or identification numberGP-PA0330
Number of Individuals Covered363
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $42,490
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,704
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10232604
Policy instance 2
Insurance contract or identification number10232604
Number of Individuals Covered154
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $4,203
Total amount of fees paid to insurance companyUSD $1,954
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,203
Amount paid for insurance broker fees1954
Additional information about fees paid to insurance brokerFEES OVERRIDE
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number617229
Policy instance 1
Insurance contract or identification number617229
Number of Individuals Covered180
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $7,829
Total amount of fees paid to insurance companyUSD $4,474
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $129,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees4474
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10232604
Policy instance 2
Insurance contract or identification number10232604
Number of Individuals Covered147
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $4,015
Total amount of fees paid to insurance companyUSD $1,780
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,015
Amount paid for insurance broker fees1780
Additional information about fees paid to insurance brokerFEES OVERRIDES
Insurance broker organization code?3
AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 )
Policy contract numberGP-PA0330
Policy instance 3
Insurance contract or identification numberGP-PA0330
Number of Individuals Covered285
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $28,861
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,577
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGM607887
Policy instance 4
Insurance contract or identification numberSGM607887
Number of Individuals Covered147
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $2,773
Total amount of fees paid to insurance companyUSD $1,459
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $29,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,773
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSALES AND SERVICE
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number617229
Policy instance 1
Insurance contract or identification number617229
Number of Individuals Covered133
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $7,127
Total amount of fees paid to insurance companyUSD $4,073
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $116,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,127
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerGENERAL AGENT PAYMENTS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10232604
Policy instance 2
Insurance contract or identification number10232604
Number of Individuals Covered144
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $3,060
Total amount of fees paid to insurance companyUSD $2,100
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0617229
Policy instance 1
Insurance contract or identification number0617229
Number of Individuals Covered141
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $6,029
Total amount of fees paid to insurance companyUSD $3,445
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $96,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract numberSGM607887
Policy instance 4
Insurance contract or identification numberSGM607887
Number of Individuals Covered169
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $2,606
Total amount of fees paid to insurance companyUSD $924
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $27,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 )
Policy contract numberGP-PA0330
Policy instance 3
Insurance contract or identification numberGP-PA0330
Number of Individuals Covered324
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $29,235
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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