POLYNT COMPOSITES USA, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PCCR USA, INC. HEALTH & WELLNESS PLAN
401k plan membership statisitcs for PCCR USA, INC. HEALTH & WELLNESS PLAN
| Measure | Date | Value |
|---|
| 2022: PCCR USA, INC. HEALTH & WELLNESS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 754 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 760 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 769 |
| 2021: PCCR USA, INC. HEALTH & WELLNESS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 738 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 741 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 754 |
| 2020: PCCR USA, INC. HEALTH & WELLNESS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 767 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 729 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 736 |
| 2019: PCCR USA, INC. HEALTH & WELLNESS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 767 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 751 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 758 |
| 2018: PCCR USA, INC. HEALTH & WELLNESS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 379 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 499 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 499 |
| 2017: PCCR USA, INC. HEALTH & WELLNESS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 371 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 379 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 379 |
| 2016: PCCR USA, INC. HEALTH & WELLNESS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 371 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 371 |
| 2015: PCCR USA, INC. HEALTH & WELLNESS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 265 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 265 |
| 2014: PCCR USA, INC. HEALTH & WELLNESS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 488 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 209 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 209 |
| 2013: PCCR USA, INC. HEALTH & WELLNESS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 488 |
| Total of all active and inactive participants | 2013-01-01 | 488 |
| Total participants | 2013-01-01 | 0 |
| 2012: PCCR USA, INC. HEALTH & WELLNESS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 208 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 209 |
| Total of all active and inactive participants | 2012-01-01 | 209 |
| Total participants | 2012-01-01 | 0 |
| 2011: PCCR USA, INC. HEALTH & WELLNESS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 564 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 208 |
| Total of all active and inactive participants | 2011-06-01 | 208 |
| Total participants | 2011-06-01 | 208 |
| 2022: PCCR USA, INC. HEALTH & WELLNESS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PCCR USA, INC. HEALTH & WELLNESS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PCCR USA, INC. HEALTH & WELLNESS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PCCR USA, INC. HEALTH & WELLNESS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PCCR USA, INC. HEALTH & WELLNESS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PCCR USA, INC. HEALTH & WELLNESS PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PCCR USA, INC. HEALTH & WELLNESS PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | First time form 5500 has been submitted | Yes |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PCCR USA, INC. HEALTH & WELLNESS PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PCCR USA, INC. HEALTH & WELLNESS PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PCCR USA, INC. HEALTH & WELLNESS PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PCCR USA, INC. HEALTH & WELLNESS PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: PCCR USA, INC. HEALTH & WELLNESS PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | First time form 5500 has been submitted | Yes |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 804916G |
| Policy instance | 2 |
| Insurance contract or identification number | 804916G | | Number of Individuals Covered | 760 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $32,383 | | Total amount of fees paid to insurance company | USD $32,758 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D,VOL.ACCIDENT, EAP,CI,HI,FMLA | | Welfare Benefit Premiums Paid to Carrier | USD $634,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 32758 | | Additional information about fees paid to insurance broker | FEES PAID BONUS PAID | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $32,383 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 1 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 1319 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 804916G |
| Policy instance | 2 |
| Insurance contract or identification number | 804916G | | Number of Individuals Covered | 741 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $28,845 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D,VOL.ACCIDENT, EAP,CI,HI,FMLA | | Welfare Benefit Premiums Paid to Carrier | USD $626,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,845 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 1 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 1331 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,784 | | 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 number | MULTIPLE |
| Policy instance | 1 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 1375 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 804916G |
| Policy instance | 2 |
| Insurance contract or identification number | 804916G | | Number of Individuals Covered | 729 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $29,910 | | Total amount of fees paid to insurance company | USD $6,620 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D, VOLUNTARY ACCIDENT, CI AND HI | | Welfare Benefit Premiums Paid to Carrier | USD $550,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,910 | | Amount paid for insurance broker fees | 6620 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | MULTIPLE |
| Policy instance | 1 |
| Insurance contract or identification number | MULTIPLE | | Number of Individuals Covered | 1349 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $93,126 | | 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 | 0835810-DEATH |
| Policy instance | 2 |
| Insurance contract or identification number | 0835810-DEATH | | Number of Individuals Covered | 751 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $332,487 | | 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 | 0835810-DISABIL |
| Policy instance | 3 |
| Insurance contract or identification number | 0835810-DISABIL | | Number of Individuals Covered | 749 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,932 | | 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 | 0835810-AD&D |
| Policy instance | 4 |
| Insurance contract or identification number | 0835810-AD&D | | Number of Individuals Covered | 751 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $33,425 | | 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 number | 10083771001, 2 |
| Policy instance | 1 |
| Insurance contract or identification number | 10083771001, 2 | | Number of Individuals Covered | 838 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,695 | | 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 | 0835810-DEATH |
| Policy instance | 2 |
| Insurance contract or identification number | 0835810-DEATH | | Number of Individuals Covered | 499 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $208,272 | | 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 | 0835810-DISABIL |
| Policy instance | 3 |
| Insurance contract or identification number | 0835810-DISABIL | | Number of Individuals Covered | 498 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,964 | | 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 | 0835810-AD&D |
| Policy instance | 4 |
| Insurance contract or identification number | 0835810-AD&D | | Number of Individuals Covered | 499 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $22,599 | | 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 | 0835810-SL |
| Policy instance | 6 |
| Insurance contract or identification number | 0835810-SL | | Number of Individuals Covered | 358 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $52,614 | | Welfare Benefit Premiums Paid to Carrier | USD $538,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,614 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338676 |
| Policy instance | 5 |
| Insurance contract or identification number | 3338676 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $322,099 | | 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 | 0835810-AD&D |
| Policy instance | 4 |
| Insurance contract or identification number | 0835810-AD&D | | Number of Individuals Covered | 423 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $174 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $27,219 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 174 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0835810-DISABIL |
| Policy instance | 3 |
| Insurance contract or identification number | 0835810-DISABIL | | Number of Individuals Covered | 421 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,058 | | 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 | 0835810-DEATH |
| Policy instance | 2 |
| Insurance contract or identification number | 0835810-DEATH | | Number of Individuals Covered | 423 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $158,092 | | 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 number | 10083771001, 2 |
| Policy instance | 1 |
| Insurance contract or identification number | 10083771001, 2 | | Number of Individuals Covered | 684 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30026354 |
| Policy instance | 1 |
| Insurance contract or identification number | 30026354 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $733 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $733 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN CORP, INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0835810 |
| Policy instance | 2 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $114,842 | | 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 | 0835810 |
| Policy instance | 3 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,593 | | 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 | 0835810 |
| Policy instance | 4 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $26,002 | | 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 | 0835810 |
| Policy instance | 5 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 566 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $168,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30026354 |
| Policy instance | 2 |
| Insurance contract or identification number | 30026354 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 233089 |
| Policy instance | 1 |
| Insurance contract or identification number | 233089 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,542 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $170,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,542 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0835810 |
| Policy instance | 3 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $110,110 | | 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 | 0835810 |
| Policy instance | 4 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,483 | | 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 | 0835810 |
| Policy instance | 5 |
| Insurance contract or identification number | 0835810 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $28,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30026354 |
| Policy instance | 2 |
| Insurance contract or identification number | 30026354 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,627 | | 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 | 835810 |
| Policy instance | 1 |
| Insurance contract or identification number | 835810 | | Number of Individuals Covered | 509 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,843,523 | | 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 | 835810 |
| Policy instance | 2 |
| Insurance contract or identification number | 835810 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,817,492 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30026354 |
| Policy instance | 1 |
| Insurance contract or identification number | 30026354 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,690 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30026354 |
| Policy instance | 1 |
| Insurance contract or identification number | 30026354 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2011-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,117 | | 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 | 835810 |
| Policy instance | 2 |
| Insurance contract or identification number | 835810 | | Number of Individuals Covered | 564 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2011-12-31 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,616,111 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
