CITIZENS BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CITIZENS BANK HEALTH AND WELFARE PLAN
Measure | Date | Value |
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2022: CITIZENS BANK HEALTH AND WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-05-01 | 135 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 133 |
Number of retired or separated participants receiving benefits | 2022-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-05-01 | 0 |
Total of all active and inactive participants | 2022-05-01 | 133 |
Number of employers contributing to the scheme | 2022-05-01 | 0 |
2021: CITIZENS BANK HEALTH AND WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-05-01 | 123 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 135 |
Number of retired or separated participants receiving benefits | 2021-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-05-01 | 0 |
Total of all active and inactive participants | 2021-05-01 | 135 |
Number of employers contributing to the scheme | 2021-05-01 | 0 |
2020: CITIZENS BANK HEALTH AND WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-05-01 | 115 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 123 |
Number of retired or separated participants receiving benefits | 2020-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-05-01 | 0 |
Total of all active and inactive participants | 2020-05-01 | 123 |
Number of employers contributing to the scheme | 2020-05-01 | 0 |
2019: CITIZENS BANK HEALTH AND WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-05-01 | 116 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 115 |
Number of retired or separated participants receiving benefits | 2019-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-05-01 | 0 |
Total of all active and inactive participants | 2019-05-01 | 115 |
Number of employers contributing to the scheme | 2019-05-01 | 0 |
2018: CITIZENS BANK HEALTH AND WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-05-01 | 117 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 114 |
Number of retired or separated participants receiving benefits | 2018-05-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 0 |
Total of all active and inactive participants | 2018-05-01 | 115 |
2017: CITIZENS BANK HEALTH AND WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-05-01 | 109 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 117 |
Number of retired or separated participants receiving benefits | 2017-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-05-01 | 0 |
Total of all active and inactive participants | 2017-05-01 | 117 |
2016: CITIZENS BANK HEALTH AND WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-05-01 | 103 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 109 |
Number of retired or separated participants receiving benefits | 2016-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-05-01 | 0 |
Total of all active and inactive participants | 2016-05-01 | 109 |
2015: CITIZENS BANK HEALTH AND WELFARE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-07-01 | 100 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 103 |
Number of retired or separated participants receiving benefits | 2015-07-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
Total of all active and inactive participants | 2015-07-01 | 103 |
2022: CITIZENS BANK HEALTH AND WELFARE PLAN 2022 form 5500 responses |
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2022-05-01 | Type of plan entity | Single employer plan |
2022-05-01 | Plan funding arrangement – Insurance | Yes |
2022-05-01 | Plan benefit arrangement – Insurance | Yes |
2021: CITIZENS BANK HEALTH AND WELFARE PLAN 2021 form 5500 responses |
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2021-05-01 | Type of plan entity | Single employer plan |
2021-05-01 | Plan funding arrangement – Insurance | Yes |
2021-05-01 | Plan benefit arrangement – Insurance | Yes |
2020: CITIZENS BANK HEALTH AND WELFARE PLAN 2020 form 5500 responses |
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2020-05-01 | Type of plan entity | Single employer plan |
2020-05-01 | Plan funding arrangement – Insurance | Yes |
2020-05-01 | Plan benefit arrangement – Insurance | Yes |
2019: CITIZENS BANK HEALTH AND WELFARE PLAN 2019 form 5500 responses |
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2019-05-01 | Type of plan entity | Single employer plan |
2019-05-01 | Plan funding arrangement – Insurance | Yes |
2019-05-01 | Plan benefit arrangement – Insurance | Yes |
2018: CITIZENS BANK HEALTH AND WELFARE PLAN 2018 form 5500 responses |
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2018-05-01 | Type of plan entity | Single employer plan |
2018-05-01 | Submission has been amended | No |
2018-05-01 | This submission is the final filing | No |
2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-05-01 | Plan is a collectively bargained plan | No |
2018-05-01 | Plan funding arrangement – Insurance | Yes |
2018-05-01 | Plan benefit arrangement – Insurance | Yes |
2017: CITIZENS BANK HEALTH AND WELFARE PLAN 2017 form 5500 responses |
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2017-05-01 | Type of plan entity | Single employer plan |
2017-05-01 | Submission has been amended | No |
2017-05-01 | This submission is the final filing | No |
2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-05-01 | Plan is a collectively bargained plan | No |
2017-05-01 | Plan funding arrangement – Insurance | Yes |
2017-05-01 | Plan benefit arrangement – Insurance | Yes |
2016: CITIZENS BANK HEALTH AND WELFARE PLAN 2016 form 5500 responses |
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2016-05-01 | Type of plan entity | Single employer plan |
2016-05-01 | Submission has been amended | Yes |
2016-05-01 | This submission is the final filing | No |
2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-05-01 | Plan is a collectively bargained plan | No |
2016-05-01 | Plan funding arrangement – Insurance | Yes |
2016-05-01 | Plan benefit arrangement – Insurance | Yes |
2015: CITIZENS BANK HEALTH AND WELFARE PLAN 2015 form 5500 responses |
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2015-07-01 | Type of plan entity | Single employer plan |
2015-07-01 | First time form 5500 has been submitted | Yes |
2015-07-01 | Submission has been amended | No |
2015-07-01 | This submission is the final filing | No |
2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2015-07-01 | Plan is a collectively bargained plan | No |
2015-07-01 | Plan funding arrangement – Insurance | Yes |
2015-07-01 | Plan benefit arrangement – Insurance | Yes |
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | W13063 |
Policy instance | 3 |
Insurance contract or identification number | W13063 | Number of Individuals Covered | 224 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $60,543 | Total amount of fees paid to insurance company | USD $858 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,145,306 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $48,915 | Amount paid for insurance broker fees | 858 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
Policy contract number | ER00034921 |
Policy instance | 2 |
Insurance contract or identification number | ER00034921 | Number of Individuals Covered | 53 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-07-30 | Total amount of commissions paid to insurance broker | USD $1,360 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $10,818 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $922 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 61900 |
Policy instance | 1 |
Insurance contract or identification number | 61900 | Number of Individuals Covered | 133 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-07-30 | Total amount of commissions paid to insurance broker | USD $3,800 | Total amount of fees paid to insurance company | USD $18 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $37,999 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,800 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | W13063 |
Policy instance | 3 |
Insurance contract or identification number | W13063 | Number of Individuals Covered | 191 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $45,315 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,181,871 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $33,959 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
Policy contract number | ER00034921 |
Policy instance | 2 |
Insurance contract or identification number | ER00034921 | Number of Individuals Covered | 54 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $2,513 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $19,997 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,473 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 61900 |
Policy instance | 1 |
Insurance contract or identification number | 61900 | Number of Individuals Covered | 135 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $6,022 | Total amount of fees paid to insurance company | USD $232 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $60,222 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,022 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
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PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 61900 |
Policy instance | 1 |
Insurance contract or identification number | 61900 | Number of Individuals Covered | 123 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $6,657 | Total amount of fees paid to insurance company | USD $24 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $53,375 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,013 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
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TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
Policy contract number | ER00034921 |
Policy instance | 2 |
Insurance contract or identification number | ER00034921 | Number of Individuals Covered | 88 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,463 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $18,514 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,263 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
Policy contract number | W13063 |
Policy instance | 3 |
Insurance contract or identification number | W13063 | Number of Individuals Covered | 183 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $39,963 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,080,485 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $29,980 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
Policy contract number | ER00034921 |
Policy instance | 2 |
Insurance contract or identification number | ER00034921 | Number of Individuals Covered | 68 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,432 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $14,637 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 61900 |
Policy instance | 1 |
Insurance contract or identification number | 61900 | Number of Individuals Covered | 115 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $4,925 | Total amount of fees paid to insurance company | USD $38 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $49,248 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
Policy contract number | ER00034921 |
Policy instance | 6 |
Insurance contract or identification number | ER00034921 | Number of Individuals Covered | 114 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $1,050 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | 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 $2,641 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,050 | Insurance broker organization code? | 3 |
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PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
Policy contract number | 61900 |
Policy instance | 5 |
Insurance contract or identification number | 61900 | Number of Individuals Covered | 114 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $1,630 | Total amount of fees paid to insurance company | USD $10 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $16,302 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,630 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 10 | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606887 |
Policy instance | 4 |
Insurance contract or identification number | SGD 606887 | Number of Individuals Covered | 114 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,575 | Total amount of fees paid to insurance company | USD $144 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $15,749 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,575 | Amount paid for insurance broker fees | 144 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606888 |
Policy instance | 3 |
Insurance contract or identification number | SGD 606888 | Number of Individuals Covered | 114 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $607 | Total amount of fees paid to insurance company | USD $55 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $6,068 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $607 | Amount paid for insurance broker fees | 55 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGM 606655 |
Policy instance | 2 |
Insurance contract or identification number | SGM 606655 | Number of Individuals Covered | 114 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,116 | Total amount of fees paid to insurance company | USD $111 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | 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 $11,157 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,116 | Amount paid for insurance broker fees | 111 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK 604713 |
Policy instance | 1 |
Insurance contract or identification number | SOK 604713 | Number of Individuals Covered | 114 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $144 | Total amount of fees paid to insurance company | USD $16 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $1,445 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $144 | Amount paid for insurance broker fees | 16 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK 604713 |
Policy instance | 1 |
Insurance contract or identification number | SOK 604713 | Number of Individuals Covered | 117 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $249 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | 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 $2,340 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGM 606655 |
Policy instance | 2 |
Insurance contract or identification number | SGM 606655 | Number of Individuals Covered | 117 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $1,721 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | 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 $16,211 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606888 |
Policy instance | 3 |
Insurance contract or identification number | SGD 606888 | Number of Individuals Covered | 117 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $863 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $8,118 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606887 |
Policy instance | 4 |
Insurance contract or identification number | SGD 606887 | Number of Individuals Covered | 117 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $2,240 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $21,062 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606887 |
Policy instance | 4 |
Insurance contract or identification number | SGD 606887 | Number of Individuals Covered | 103 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $1,349 | Total amount of fees paid to insurance company | USD $25 | 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | 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 $13,489 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,349 | Amount paid for insurance broker fees | 25 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD 606888 |
Policy instance | 3 |
Insurance contract or identification number | SGD 606888 | Number of Individuals Covered | 103 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $520 | Total amount of fees paid to insurance company | USD $10 | 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 | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $5,198 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $520 | Amount paid for insurance broker fees | 10 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGM 606655 |
Policy instance | 2 |
Insurance contract or identification number | SGM 606655 | Number of Individuals Covered | 133 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $591 | Total amount of fees paid to insurance company | USD $11 | 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 | No | Vision Insurance Welfare Benefit | No | 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 $5,909 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $591 | Amount paid for insurance broker fees | 11 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK 604713 |
Policy instance | 1 |
Insurance contract or identification number | SOK 604713 | Number of Individuals Covered | 111 | Insurance policy start date | 2015-07-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $91 | Total amount of fees paid to insurance company | USD $1 | 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 | 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 | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | 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 $909 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $91 | Amount paid for insurance broker fees | 1 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSION | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
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