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CO-OP 401(K) PLAN 401k Plan overview

Plan NameCO-OP 401(K) PLAN
Plan identification number 003

CO-OP 401(K) PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
  • Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
  • Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

LEGACY COOPERATIVE has sponsored the creation of one or more 401k plans.

Company Name:LEGACY COOPERATIVE
Employer identification number (EIN):450383739
NAIC Classification:115110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CO-OP 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0032022-01-01
0032021-01-01
0032020-01-01
0032019-01-01ERICA PETERS2020-07-27
0032018-01-01ERICA PETERS2019-09-30
0032017-01-01ERICA PETERS2018-10-08
0032016-01-01LYNNETTE BERG2017-05-02
0032015-01-01LYNNETTE BERG2016-06-18
0032014-01-01LYNNETTE BERG2015-08-28
0032013-01-01LYNNETTE BERG2014-07-12
0032012-01-01LYNNETTE BERG2013-05-24
0032011-01-01LYNNETTE BERG2012-06-19
0032009-01-01MIKE GRATTON

Plan Statistics for CO-OP 401(K) PLAN

401k plan membership statisitcs for CO-OP 401(K) PLAN

Measure Date Value
2022: CO-OP 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01137
Total number of active participants reported on line 7a of the Form 55002022-01-01110
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-0122
Total of all active and inactive participants2022-01-01132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2022-01-011
Total participants2022-01-01133
Number of participants with account balances2022-01-01111
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2022-01-010
2021: CO-OP 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01148
Total number of active participants reported on line 7a of the Form 55002021-01-01109
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-0126
Total of all active and inactive participants2021-01-01135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2021-01-010
Total participants2021-01-01135
Number of participants with account balances2021-01-01116
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2021-01-010
2020: CO-OP 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01143
Total number of active participants reported on line 7a of the Form 55002020-01-01123
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-0125
Total of all active and inactive participants2020-01-01148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2020-01-010
Total participants2020-01-01148
Number of participants with account balances2020-01-01118
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2020-01-010
2009: CO-OP 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-0131
Total number of active participants reported on line 7a of the Form 55002009-01-0129
Number of retired or separated participants receiving benefits2009-01-011
Number of other retired or separated participants entitled to future benefits2009-01-011
Total of all active and inactive participants2009-01-0131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010
Total participants2009-01-0131
Number of participants with account balances2009-01-0125
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2009-01-010

Financial Data on CO-OP 401(K) PLAN

Measure Date Value
2022 : CO-OP 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$1,133
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$1,399
Total income from all sources (including contributions)2022-12-31$-837,635
Total loss/gain on sale of assets2022-12-31$0
Total of all expenses incurred2022-12-31$1,545,557
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$1,504,824
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$747,384
Value of total assets at end of year2022-12-31$8,969,697
Value of total assets at beginning of year2022-12-31$11,353,155
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$40,733
Total interest from all sources2022-12-31$4,750
Total dividends received (eg from common stock, registered investment company shares)2022-12-31$248,636
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Total dividends received from registered investment company shares (eg mutual funds)2022-12-31$248,636
Administrative expenses professional fees incurred2022-12-31$38,322
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$1,000,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$495,736
Participant contributions at end of year2022-12-31$63,442
Participant contributions at beginning of year2022-12-31$107,805
Participant contributions at end of year2022-12-31$13,627
Participant contributions at beginning of year2022-12-31$16,811
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2022-12-31$1,133
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2022-12-31$1,399
Other income not declared elsewhere2022-12-31$-130,664
Administrative expenses (other) incurred2022-12-31$2,411
Total non interest bearing cash at end of year2022-12-31$9,739
Total non interest bearing cash at beginning of year2022-12-31$46,030
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$-2,383,192
Value of net assets at end of year (total assets less liabilities)2022-12-31$8,968,564
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$11,351,756
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2022-12-31$7,668,015
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2022-12-31$9,424,318
Interest on participant loans2022-12-31$4,750
Value of interest in common/collective trusts at end of year2022-12-31$25,909
Value of interest in common/collective trusts at beginning of year2022-12-31$75,151
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2022-12-31$224
Asset value of US Government securities at end of year2022-12-31$372,174
Asset value of US Government securities at beginning of year2022-12-31$726,494
Net investment gain/loss from registered investment companies (e.g. mutual funds)2022-12-31$-1,708,246
Net investment gain or loss from common/collective trusts2022-12-31$505
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31Yes
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$251,648
Employer contributions (assets) at beginning of year2022-12-31$9,731
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-12-31$1,504,824
Asset. Corporate debt instrument preferred debt at end of year2022-12-31$286,559
Asset. Corporate debt instrument preferred debt at beginning of year2022-12-31$319,758
Asset. Corporate debt instrument debt (other) at end of year2022-12-31$530,008
Asset. Corporate debt instrument debt (other) at beginning of year2022-12-31$627,057
Did the plan have assets held for investment2022-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31EIDE BAILLY
Accountancy firm EIN2022-12-31450250958
2021 : CO-OP 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$1,399
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$1,526
Total income from all sources (including contributions)2021-12-31$1,757,928
Total loss/gain on sale of assets2021-12-31$0
Total of all expenses incurred2021-12-31$1,594,004
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$1,552,100
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$750,269
Value of total assets at end of year2021-12-31$11,353,155
Value of total assets at beginning of year2021-12-31$11,189,358
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$41,904
Total interest from all sources2021-12-31$6,028
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$427,787
Total dividends received from registered investment company shares (eg mutual funds)2021-12-31$427,787
Administrative expenses professional fees incurred2021-12-31$39,105
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$1,000,000
If this is an individual account plan, was there a blackout period2021-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2021-12-31$0
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$450,664
Participant contributions at end of year2021-12-31$107,805
Participant contributions at beginning of year2021-12-31$116,898
Participant contributions at end of year2021-12-31$16,811
Participant contributions at beginning of year2021-12-31$14,844
Income. Received or receivable in cash from other sources (including rollovers)2021-12-31$59,350
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2021-12-31$1,399
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2021-12-31$1,526
Other income not declared elsewhere2021-12-31$-70,295
Administrative expenses (other) incurred2021-12-31$2,799
Total non interest bearing cash at end of year2021-12-31$46,030
Total non interest bearing cash at beginning of year2021-12-31$114
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$163,924
Value of net assets at end of year (total assets less liabilities)2021-12-31$11,351,756
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$11,187,832
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2021-12-31$9,424,318
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2021-12-31$9,077,716
Interest on participant loans2021-12-31$6,028
Value of interest in common/collective trusts at end of year2021-12-31$75,151
Value of interest in common/collective trusts at beginning of year2021-12-31$164,801
Asset value of US Government securities at end of year2021-12-31$726,494
Asset value of US Government securities at beginning of year2021-12-31$828,729
Net investment gain/loss from registered investment companies (e.g. mutual funds)2021-12-31$644,094
Net investment gain or loss from common/collective trusts2021-12-31$45
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31Yes
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$240,255
Employer contributions (assets) at end of year2021-12-31$9,731
Employer contributions (assets) at beginning of year2021-12-31$8,185
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$1,552,100
Asset. Corporate debt instrument preferred debt at end of year2021-12-31$319,758
Asset. Corporate debt instrument preferred debt at beginning of year2021-12-31$366,350
Asset. Corporate debt instrument debt (other) at end of year2021-12-31$627,057
Asset. Corporate debt instrument debt (other) at beginning of year2021-12-31$611,721
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31EIDE BAILLY
Accountancy firm EIN2021-12-31450250958
2020 : CO-OP 401(K) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$1,526
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$1,562
Total income from all sources (including contributions)2020-12-31$2,959,211
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$746,789
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$708,361
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,259,837
Value of total assets at end of year2020-12-31$11,189,358
Value of total assets at beginning of year2020-12-31$8,976,972
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$38,428
Total interest from all sources2020-12-31$6,547
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$288,213
Total dividends received from registered investment company shares (eg mutual funds)2020-12-31$288,213
Administrative expenses professional fees incurred2020-12-31$35,586
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$1,000,000
If this is an individual account plan, was there a blackout period2020-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2020-12-31$0
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$459,353
Participant contributions at end of year2020-12-31$116,898
Participant contributions at beginning of year2020-12-31$129,317
Participant contributions at end of year2020-12-31$14,844
Income. Received or receivable in cash from other sources (including rollovers)2020-12-31$564,494
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2020-12-31$1,526
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2020-12-31$1,562
Other income not declared elsewhere2020-12-31$154,226
Administrative expenses (other) incurred2020-12-31$2,842
Total non interest bearing cash at end of year2020-12-31$114
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$2,212,422
Value of net assets at end of year (total assets less liabilities)2020-12-31$11,187,832
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$8,975,410
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2020-12-31$9,077,716
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2020-12-31$7,057,111
Interest on participant loans2020-12-31$6,547
Value of interest in common/collective trusts at end of year2020-12-31$164,801
Value of interest in common/collective trusts at beginning of year2020-12-31$84,358
Asset value of US Government securities at end of year2020-12-31$828,729
Asset value of US Government securities at beginning of year2020-12-31$649,386
Net investment gain/loss from registered investment companies (e.g. mutual funds)2020-12-31$1,249,977
Net investment gain or loss from common/collective trusts2020-12-31$411
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$235,990
Employer contributions (assets) at end of year2020-12-31$8,185
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$708,361
Asset. Corporate debt instrument preferred debt at end of year2020-12-31$366,350
Asset. Corporate debt instrument preferred debt at beginning of year2020-12-31$377,945
Asset. Corporate debt instrument debt (other) at end of year2020-12-31$611,721
Asset. Corporate debt instrument debt (other) at beginning of year2020-12-31$678,855
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31EIDE BAILLY
Accountancy firm EIN2020-12-31450250958
2010 : CO-OP 401(K) PLAN 2010 401k financial data
Total plan liabilities at end of year2010-12-31$0
Total plan liabilities at beginning of year2010-12-31$0
Total income from all sources2010-12-31$465,898
Expenses. Total of all expenses incurred2010-12-31$37,835
Benefits paid (including direct rollovers)2010-12-31$23,420
Total plan assets at end of year2010-12-31$2,159,902
Total plan assets at beginning of year2010-12-31$1,731,839
Value of fidelity bond covering the plan2010-12-31$300,000
Total contributions received or receivable from participants2010-12-31$125,691
Expenses. Other expenses not covered elsewhere2010-12-31$14,415
Contributions received from other sources (not participants or employers)2010-12-31$959
Other income received2010-12-31$293,403
Net income (gross income less expenses)2010-12-31$428,063
Net plan assets at end of year (total assets less liabilities)2010-12-31$2,159,902
Net plan assets at beginning of year (total assets less liabilities)2010-12-31$1,731,839
Assets. Value of participant loans2010-12-31$69,083
Total contributions received or receivable from employer(s)2010-12-31$45,845
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2010-12-31$0
2009 : CO-OP 401(K) PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2009-12-31$0

Form 5500 Responses for CO-OP 401(K) PLAN

2022: CO-OP 401(K) PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: CO-OP 401(K) PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: CO-OP 401(K) PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2009: CO-OP 401(K) PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – TrustYes
2009-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract numberMDA01360TR
Policy instance 4
Insurance contract or identification numberMDA01360TR
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number062491
Policy instance 3
Insurance contract or identification number062491
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )
Policy contract numberG-027795
Policy instance 2
Insurance contract or identification numberG-027795
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract number1666920
Policy instance 1
Insurance contract or identification number1666920
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract numberMDA01360TR
Policy instance 4
Insurance contract or identification numberMDA01360TR
Number of Individuals Covered135
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number062491
Policy instance 3
Insurance contract or identification number062491
Number of Individuals Covered135
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )
Policy contract numberG-027795
Policy instance 2
Insurance contract or identification numberG-027795
Number of Individuals Covered135
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract number1666920
Policy instance 1
Insurance contract or identification number1666920
Number of Individuals Covered135
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
MONUMENTAL LIFE (National Association of Insurance Commissioners NAIC id number: 66281 )
Policy contract numberMDA01360TR
Policy instance 4
Insurance contract or identification numberMDA01360TR
Number of Individuals Covered148
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number062491
Policy instance 3
Insurance contract or identification number062491
Number of Individuals Covered148
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )
Policy contract numberG-027795
Policy instance 2
Insurance contract or identification numberG-027795
Number of Individuals Covered148
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract number1666920
Policy instance 1
Insurance contract or identification number1666920
Number of Individuals Covered148
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No

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