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GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 401k Plan overview

Plan NameGROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES
Plan identification number 503

GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

PIGGLY WIGGLY MIDWEST, LLC has sponsored the creation of one or more 401k plans.

Company Name:PIGGLY WIGGLY MIDWEST, LLC
Employer identification number (EIN):450575370
NAIC Classification:424400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032020-01-01
5032019-01-01
5032018-01-01MICHAEL ISKEN MICHAEL ISKEN2019-05-20
5032017-01-01MICHAEL ISKEN MICHAEL ISKEN2018-10-10
5032016-01-01MICHAEL ISKEN MICHAEL ISKEN2017-10-13
5032015-01-01MICHAEL ISKEN MICHAEL ISKEN2016-10-13
5032014-01-01MICHAEL ISKEN MICHAEL ISKEN2015-10-07
5032013-01-01MICHAEL ISKEN MICHAEL ISKEN2014-07-29
5032012-01-01MICHAEL ISKEN MICHAEL ISKEN2013-07-29
5032011-01-01MICHAEL ISKEN
5032010-01-01MICHAEL ISKEN
5032009-01-01 MICHAEL ISKEN2010-07-26
5032009-01-01MICHAEL ISKEN

Plan Statistics for GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES

401k plan membership statisitcs for GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES

Measure Date Value
2020: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2020 401k membership
Total participants, beginning-of-year2020-01-01586
Total number of active participants reported on line 7a of the Form 55002020-01-01508
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01508
2019: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2019 401k membership
Total participants, beginning-of-year2019-01-01605
Total number of active participants reported on line 7a of the Form 55002019-01-01586
Total of all active and inactive participants2019-01-01586
Total participants2019-01-01586
2018: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2018 401k membership
Total participants, beginning-of-year2018-01-01610
Total number of active participants reported on line 7a of the Form 55002018-01-01617
Total of all active and inactive participants2018-01-01617
Total participants2018-01-01617
2017: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2017 401k membership
Total participants, beginning-of-year2017-01-01684
Total number of active participants reported on line 7a of the Form 55002017-01-01624
Total of all active and inactive participants2017-01-01624
Total participants2017-01-01624
2016: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2016 401k membership
Total participants, beginning-of-year2016-01-01634
Total number of active participants reported on line 7a of the Form 55002016-01-01632
Total of all active and inactive participants2016-01-01632
Total participants2016-01-01632
2015: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2015 401k membership
Total participants, beginning-of-year2015-01-01576
Total number of active participants reported on line 7a of the Form 55002015-01-01589
Total of all active and inactive participants2015-01-01589
Total participants2015-01-01589
2014: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2014 401k membership
Total participants, beginning-of-year2014-01-01522
Total number of active participants reported on line 7a of the Form 55002014-01-01572
Total of all active and inactive participants2014-01-01572
Total participants2014-01-01572
2013: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2013 401k membership
Total participants, beginning-of-year2013-01-01522
Total number of active participants reported on line 7a of the Form 55002013-01-01522
Total of all active and inactive participants2013-01-01522
Total participants2013-01-01522
2012: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2012 401k membership
Total participants, beginning-of-year2012-01-01575
Total number of active participants reported on line 7a of the Form 55002012-01-01522
Total of all active and inactive participants2012-01-01522
Total participants2012-01-01522
2011: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2011 401k membership
Total participants, beginning-of-year2011-01-01583
Total number of active participants reported on line 7a of the Form 55002011-01-01575
Total of all active and inactive participants2011-01-01575
Total participants2011-01-01575
2010: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2010 401k membership
Total participants, beginning-of-year2010-01-01615
Total number of active participants reported on line 7a of the Form 55002010-01-01583
Total of all active and inactive participants2010-01-01583
Total participants2010-01-01583
2009: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2009 401k membership
Total participants, beginning-of-year2009-01-01639
Total number of active participants reported on line 7a of the Form 55002009-01-01615
Total of all active and inactive participants2009-01-01615
Total participants2009-01-01615

Form 5500 Responses for GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES

2020: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 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 filingYes
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 benefit arrangement – InsuranceYes
2019: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedYes
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: GROUP LIFE INSURANCE PLAN FOR UNIONIZED HOURLY RATED EMPLOYEES AND OTHER EMPLOYEES 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 planYes
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967930
Policy instance 2
Insurance contract or identification numberFLX967930
Number of Individuals Covered508
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $10,205
Total amount of fees paid to insurance companyUSD $393
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $102,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,205
Insurance broker organization code?3
Amount paid for insurance broker fees393
Additional information about fees paid to insurance brokerOVERRIDE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK969418
Policy instance 1
Insurance contract or identification numberOK969418
Number of Individuals Covered508
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $805
Total amount of fees paid to insurance companyUSD $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?No
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
Other welfare benefits providedAD&D
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 CarrierUSD $8,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $805
Insurance broker organization code?3
Amount paid for insurance broker fees31
Additional information about fees paid to insurance brokerOVERRIDE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967930
Policy instance 2
Insurance contract or identification numberFLX967930
Number of Individuals Covered586
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $10,254
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $102,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,254
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK969418
Policy instance 1
Insurance contract or identification numberOK969418
Number of Individuals Covered480
Insurance policy start date2019-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $808
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?No
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
Other welfare benefits providedACCIDENT 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 CarrierUSD $8,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $808
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK969418
Policy instance 2
Insurance contract or identification numberOK969418
Number of Individuals Covered502
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $828
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?No
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
Other welfare benefits providedACCIDENT 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 CarrierUSD $8,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $345
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967930
Policy instance 1
Insurance contract or identification numberFLX967930
Number of Individuals Covered610
Insurance policy start date2018-06-01
Insurance policy end date2019-06-01
Total amount of commissions paid to insurance brokerUSD $10,348
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $103,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,277
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967930
Policy instance 4
Insurance contract or identification numberFLX967930
Number of Individuals Covered624
Insurance policy start date2017-06-01
Insurance policy end date2018-06-01
Total amount of commissions paid to insurance brokerUSD $9,587
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $95,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,210
Insurance broker organization code?3
Insurance broker nameJEROME J. MANCUSO & ASSOCIATES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK969418
Policy instance 3
Insurance contract or identification numberOK969418
Number of Individuals Covered508
Insurance policy start date2017-06-01
Insurance policy end date2018-06-01
Total amount of commissions paid to insurance brokerUSD $766
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?No
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
Other welfare benefits providedACCIDENTAL DEATH
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 CarrierUSD $7,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $416
Insurance broker organization code?3
Insurance broker nameJEROME J. MANCUSO & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL156780
Policy instance 2
Insurance contract or identification numberGL156780
Number of Individuals Covered560
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,995
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $19,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,995
Insurance broker organization code?3
Insurance broker nameJEROME J. MANCUSO & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL156774
Policy instance 1
Insurance contract or identification numberGL156774
Number of Individuals Covered124
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $914
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?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $914
Insurance broker organization code?3
Insurance broker nameJEROME J. MANCUSO & ASSOCIATES

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