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DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameDIVERSIFIED ROOFING HEALTH AND WELFARE PLAN
Plan identification number 502

DIVERSIFIED ROOFING HEALTH AND WELFARE 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

DIVERSIFIED ROOFING CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:DIVERSIFIED ROOFING CORPORATION
Employer identification number (EIN):860599690
NAIC Classification:238100

Additional information about DIVERSIFIED ROOFING CORPORATION

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2008-11-14
Company Identification Number: 0801052150
Legal Registered Office Address: 2015 W MOUNTAIN VIEW RD

PHOENIX
United States of America (USA)
85021

More information about DIVERSIFIED ROOFING CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022021-09-01MARK SCHOUTEN2023-02-02
5022020-09-01AMY STROUSE2022-03-30
5022019-09-01
5022019-09-01
5022018-09-01
5022017-09-01
5022017-04-01
5022016-04-01 MARK SCHOUTEN2020-12-09
5022015-04-01
5022014-04-01
5022013-04-01
5022012-04-01
5022011-04-01
5022010-04-01WILLIAM J. MORONEY
5022009-04-01WILLIAM J. MORONEY

Plan Statistics for DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN

401k plan membership statisitcs for DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN

Measure Date Value
2021: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-01258
Total number of active participants reported on line 7a of the Form 55002021-09-01247
Number of retired or separated participants receiving benefits2021-09-010
Number of other retired or separated participants entitled to future benefits2021-09-010
Total of all active and inactive participants2021-09-01247
Number of employers contributing to the scheme2021-09-010
2020: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01253
Total number of active participants reported on line 7a of the Form 55002020-09-01258
Number of retired or separated participants receiving benefits2020-09-010
Number of other retired or separated participants entitled to future benefits2020-09-010
Total of all active and inactive participants2020-09-01258
Number of employers contributing to the scheme2020-09-010
2019: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01206
Total number of active participants reported on line 7a of the Form 55002019-09-01252
Number of retired or separated participants receiving benefits2019-09-011
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01253
2018: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01226
Total number of active participants reported on line 7a of the Form 55002018-09-01205
Number of retired or separated participants receiving benefits2018-09-011
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01206
2017: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01138
Total number of active participants reported on line 7a of the Form 55002017-09-01224
Number of retired or separated participants receiving benefits2017-09-012
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-01226
Total participants, beginning-of-year2017-04-01160
Total number of active participants reported on line 7a of the Form 55002017-04-01138
Number of retired or separated participants receiving benefits2017-04-010
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01138
2016: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01104
Total number of active participants reported on line 7a of the Form 55002016-04-01160
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01160
2015: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01186
Total number of active participants reported on line 7a of the Form 55002015-04-01103
Number of retired or separated participants receiving benefits2015-04-011
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01104
2014: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01165
Total number of active participants reported on line 7a of the Form 55002014-04-01182
Number of retired or separated participants receiving benefits2014-04-014
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01186
2013: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-01101
Total number of active participants reported on line 7a of the Form 55002013-04-01163
Number of retired or separated participants receiving benefits2013-04-012
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01165
2012: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-04-01103
Total number of active participants reported on line 7a of the Form 55002012-04-01100
Number of retired or separated participants receiving benefits2012-04-011
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01101
2011: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-01125
Total number of active participants reported on line 7a of the Form 55002011-04-01100
Number of retired or separated participants receiving benefits2011-04-013
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-01103
2010: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year2010-04-01168
Total number of active participants reported on line 7a of the Form 55002010-04-01121
Number of retired or separated participants receiving benefits2010-04-014
Number of other retired or separated participants entitled to future benefits2010-04-010
Total of all active and inactive participants2010-04-01125
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2010-04-010
2009: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-04-01335
Total number of active participants reported on line 7a of the Form 55002009-04-01159
Number of retired or separated participants receiving benefits2009-04-019
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01168
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-04-010
Total participants2009-04-01168

Form 5500 Responses for DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN

2021: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-09-01Type of plan entitySingle employer plan
2021-09-01Plan funding arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – InsuranceYes
2020: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – InsuranceYes
2019: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedNo
2019-09-01This submission is the final filingNo
2019-09-01This return/report is a short plan year return/report (less than 12 months)No
2019-09-01Plan is a collectively bargained planNo
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – InsuranceYes
2018: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan funding arrangement – General assets of the sponsorYes
2018-09-01Plan benefit arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – General assets of the sponsorYes
2017: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan funding arrangement – General assets of the sponsorYes
2017-09-01Plan benefit arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – General assets of the sponsorYes
2017-04-01Type of plan entitySingle employer plan
2017-04-01Submission has been amendedNo
2017-04-01This submission is the final filingNo
2017-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-04-01Plan is a collectively bargained planNo
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – InsuranceYes
2013: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – InsuranceYes
2012: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – InsuranceYes
2011: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – InsuranceYes
2010: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – InsuranceYes
2009: DIVERSIFIED ROOFING HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number011121
Policy instance 3
Insurance contract or identification number011121
Number of Individuals Covered247
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $2,535
Total amount of fees paid to insurance companyUSD $1,421
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $16,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,535
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 2
Insurance contract or identification number10110671001
Number of Individuals Covered99
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $540
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $540
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number38195
Policy instance 1
Insurance contract or identification number38195
Number of Individuals Covered143
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $24,236
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $448,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,236
Amount paid for insurance broker fees0
Insurance broker organization code?3
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUDAZX48919
Policy instance 1
Insurance contract or identification numberEUDAZX48919
Number of Individuals Covered107
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $1,631
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,631
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number38195
Policy instance 2
Insurance contract or identification number38195
Number of Individuals Covered94
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $23,254
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $387,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,254
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 3
Insurance contract or identification number10110671001
Number of Individuals Covered80
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $493
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $493
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BLBY
Policy instance 4
Insurance contract or identification numberGLUG0BLBY
Number of Individuals Covered258
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $1,696
Total amount of fees paid to insurance companyUSD $673
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 $11,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,696
Amount paid for insurance broker fees673
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number38195
Policy instance 3
Insurance contract or identification number38195
Number of Individuals Covered49
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $23,343
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $389,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,343
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 5
Insurance contract or identification number10110671001
Number of Individuals Covered82
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $531
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $531
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BLBY
Policy instance 4
Insurance contract or identification numberGVTL0BLBY
Number of Individuals Covered30
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,378
Total amount of fees paid to insurance companyUSD $179
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $9,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,378
Amount paid for insurance broker fees179
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BLBY
Policy instance 2
Insurance contract or identification numberGLUG0BLBY
Number of Individuals Covered252
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $350
Total amount of fees paid to insurance companyUSD $23
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $2,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $350
Amount paid for insurance broker fees23
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number
Policy instance 3
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
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 1
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered107
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,705
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,705
Insurance broker organization code?3
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 1
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered124
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,405
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,405
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 3
Insurance contract or identification number10110671001
Number of Individuals Covered92
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $584
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $584
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-016996-00
Policy instance 2
Insurance contract or identification number01-016996-00
Number of Individuals Covered205
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,408
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,408
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-016996-00
Policy instance 1
Insurance contract or identification number01-016996-00
Number of Individuals Covered224
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $1,223
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 2
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered123
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $2,531
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 3
Insurance contract or identification number10110671001
Number of Individuals Covered87
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $438
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10110671001
Policy instance 3
Insurance contract or identification number10110671001
Number of Individuals Covered74
Insurance policy start date2017-04-01
Insurance policy end date2017-08-31
Total amount of commissions paid to insurance brokerUSD $165
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number
Policy instance 2
Insurance policy start date2017-04-01
Insurance policy end date2017-08-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 4
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered116
Insurance policy start date2017-04-01
Insurance policy end date2017-08-31
Total amount of commissions paid to insurance brokerUSD $1,253
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-016996-00
Policy instance 1
Insurance contract or identification number01-016996-00
Number of Individuals Covered138
Insurance policy start date2017-04-01
Insurance policy end date2017-08-31
Total amount of commissions paid to insurance brokerUSD $506
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $3,361
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 number00476644
Policy instance 3
Insurance contract or identification number00476644
Number of Individuals Covered103
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $889
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $10,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $889
Insurance broker organization code?3
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 2
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered136
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $4,190
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $78,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,190
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number
Policy instance 1
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00476644
Policy instance 3
Insurance contract or identification number00476644
Number of Individuals Covered182
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $898
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $735
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90744298/722933
Policy instance 1
Insurance contract or identification number90744298/722933
Number of Individuals Covered77
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $13,248
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $345,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,248
Insurance broker organization code?3
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberEUD AZX48919
Policy instance 2
Insurance contract or identification numberEUD AZX48919
Number of Individuals Covered164
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $3,314
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $70,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,314
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3932035
Policy instance 3
Insurance contract or identification numberE3932035
Number of Individuals Covered4
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $215
Total amount of fees paid to insurance companyUSD $31
Other welfare benefits providedVOLUNTARY WORKSITE BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $4,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70
Insurance broker organization code?3
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerFEES PAID
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00476644
Policy instance 1
Insurance contract or identification number00476644
Number of Individuals Covered163
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $3,681
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $55,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,612
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberHN1934405 01
Policy instance 2
Insurance contract or identification numberHN1934405 01
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberHN1934405 01
Policy instance 2
Insurance contract or identification numberHN1934405 01
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00476644
Policy instance 1
Insurance contract or identification number00476644
Number of Individuals Covered177
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $3,621
Total amount of fees paid to insurance companyUSD $96
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $48,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,958
Insurance broker organization code?3
Amount paid for insurance broker fees96
Additional information about fees paid to insurance brokerTOTAL FEES PAID
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3932035
Policy instance 3
Insurance contract or identification numberE3932035
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedVOLUNTARY WORKSITE BENEFITS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberHN1934405 01
Policy instance 1
Insurance contract or identification numberHN1934405 01
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1006860
Policy instance 2
Insurance contract or identification number1006860
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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