99 CENTS ONLY STORES LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan 99 CENTS ONLY STORES WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2016: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 167 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 167 |
| 2015: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 167 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 167 |
| 2014: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 144 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-02-01 | 0 |
| Total of all active and inactive participants | 2014-02-01 | 144 |
| 2013: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 114 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-02-01 | 0 |
| Total of all active and inactive participants | 2013-02-01 | 114 |
| 2012: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 151 |
| Number of retired or separated participants receiving benefits | 2012-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-02-01 | 0 |
| Total of all active and inactive participants | 2012-02-01 | 151 |
| 2011: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 149 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 204 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-02-01 | 0 |
| Total of all active and inactive participants | 2011-02-01 | 204 |
| 2010: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-03-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-03-01 | 149 |
| Number of retired or separated participants receiving benefits | 2010-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-03-01 | 0 |
| Total of all active and inactive participants | 2010-03-01 | 149 |
| 2009: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 131 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 131 |
| 2016: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | Submission has been amended | No |
| 2011-02-01 | This submission is the final filing | No |
| 2011-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-02-01 | Plan is a collectively bargained plan | No |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-03-01 | Type of plan entity | Single employer plan |
| 2010-03-01 | Submission has been amended | No |
| 2010-03-01 | This submission is the final filing | No |
| 2010-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-03-01 | Plan is a collectively bargained plan | No |
| 2010-03-01 | Plan funding arrangement – Insurance | Yes |
| 2010-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: 99 CENTS ONLY STORES WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | First time form 5500 has been submitted | Yes |
| 2009-02-01 | Submission has been amended | No |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2014-12-29 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $5,169 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $45,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,169 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN PIPER |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 11821000 |
| Policy instance | 2 |
| Insurance contract or identification number | 11821000 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $37,874 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $252,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,874 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN L. PIPER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2013-12-30 | | Insurance policy end date | 2014-12-29 | | Total amount of commissions paid to insurance broker | USD $8,134 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $66,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,134 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN PIPER |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 11821000 |
| Policy instance | 2 |
| Insurance contract or identification number | 11821000 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $26,215 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $181,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,215 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN L. PIPER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2013-12-29 | | Total amount of commissions paid to insurance broker | USD $23,012 | | Total amount of fees paid to insurance company | USD $6,203 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $234,790 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,012 | | Amount paid for insurance broker fees | 6203 | | Additional information about fees paid to insurance broker | ADMIN. FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN PIPER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $31,252 | | Total amount of fees paid to insurance company | USD $7,320 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $330,105 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,252 | | Amount paid for insurance broker fees | 7320 | | Additional information about fees paid to insurance broker | ADMIN. FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN PIPER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $30,892 | | Total amount of fees paid to insurance company | USD $9,048 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $297,950 | | 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 | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $31,175 | | Total amount of fees paid to insurance company | USD $10,300 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $326,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,175 | | Amount paid for insurance broker fees | 10300 | | Additional information about fees paid to insurance broker | ADMIN. FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ROBYN PIPER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 801577 |
| Policy instance | 1 |
| Insurance contract or identification number | 801577 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $31,175 | | Total amount of fees paid to insurance company | USD $10,300 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $326,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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