DAVID G. HORSEY & SONS, INC. has sponsored the creation of one or more 401k plans.
Additional information about DAVID G. HORSEY & SONS, INC.
Submission information for form 5500 for 401k plan DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 63 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 63 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 63 |
| 2021: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 74 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 62 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 63 |
| 2020: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 92 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 73 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 74 |
| 2019: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 83 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 91 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 92 |
| 2018: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 74 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 83 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 83 |
| 2017: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 70 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 74 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 74 |
| Measure | Date | Value |
|---|
| 2022 : DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2022 401k financial data |
|---|
| Total plan liabilities at end of year | 2022-12-31 | $111,250 |
| Total plan liabilities at beginning of year | 2022-12-31 | $85,020 |
| Total income from all sources | 2022-12-31 | $882,615 |
| Expenses. Total of all expenses incurred | 2022-12-31 | $912,096 |
| Benefits paid (including direct rollovers) | 2022-12-31 | $576,848 |
| Total plan assets at end of year | 2022-12-31 | $74,834 |
| Total plan assets at beginning of year | 2022-12-31 | $78,085 |
| Value of fidelity bond covering the plan | 2022-12-31 | $50,000 |
| Total contributions received or receivable from participants | 2022-12-31 | $117,453 |
| Expenses. Other expenses not covered elsewhere | 2022-12-31 | $300,572 |
| Contributions received from other sources (not participants or employers) | 2022-12-31 | $10,246 |
| Other income received | 2022-12-31 | $294 |
| Noncash contributions received | 2022-12-31 | $0 |
| Net income (gross income less expenses) | 2022-12-31 | $-29,481 |
| Net plan assets at end of year (total assets less liabilities) | 2022-12-31 | $-36,416 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-12-31 | $-6,935 |
| Total contributions received or receivable from employer(s) | 2022-12-31 | $754,622 |
| Value of certain deemed distributions of participant loans | 2022-12-31 | $0 |
| Value of corrective distributions | 2022-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2022-12-31 | $34,676 |
| 2021 : DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total plan liabilities at end of year | 2021-12-31 | $85,020 |
| Total plan liabilities at beginning of year | 2021-12-31 | $59,196 |
| Total income from all sources | 2021-12-31 | $847,966 |
| Expenses. Total of all expenses incurred | 2021-12-31 | $988,524 |
| Benefits paid (including direct rollovers) | 2021-12-31 | $614,675 |
| Total plan assets at end of year | 2021-12-31 | $78,085 |
| Total plan assets at beginning of year | 2021-12-31 | $192,819 |
| Value of fidelity bond covering the plan | 2021-12-31 | $50,000 |
| Total contributions received or receivable from participants | 2021-12-31 | $376,069 |
| Expenses. Other expenses not covered elsewhere | 2021-12-31 | $333,528 |
| Contributions received from other sources (not participants or employers) | 2021-12-31 | $1,632 |
| Other income received | 2021-12-31 | $403 |
| Net income (gross income less expenses) | 2021-12-31 | $-140,558 |
| Net plan assets at end of year (total assets less liabilities) | 2021-12-31 | $-6,935 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-12-31 | $133,623 |
| Total contributions received or receivable from employer(s) | 2021-12-31 | $469,862 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2021-12-31 | $40,321 |
| 2020 : DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total plan liabilities at end of year | 2020-12-31 | $59,196 |
| Total plan liabilities at beginning of year | 2020-12-31 | $116,396 |
| Total income from all sources | 2020-12-31 | $969,573 |
| Expenses. Total of all expenses incurred | 2020-12-31 | $932,246 |
| Benefits paid (including direct rollovers) | 2020-12-31 | $499,595 |
| Total plan assets at end of year | 2020-12-31 | $192,819 |
| Total plan assets at beginning of year | 2020-12-31 | $212,692 |
| Value of fidelity bond covering the plan | 2020-12-31 | $50,000 |
| Total contributions received or receivable from participants | 2020-12-31 | $404,921 |
| Expenses. Other expenses not covered elsewhere | 2020-12-31 | $361,654 |
| Contributions received from other sources (not participants or employers) | 2020-12-31 | $19,583 |
| Other income received | 2020-12-31 | $508 |
| Net income (gross income less expenses) | 2020-12-31 | $37,327 |
| Net plan assets at end of year (total assets less liabilities) | 2020-12-31 | $133,623 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-12-31 | $96,296 |
| Total contributions received or receivable from employer(s) | 2020-12-31 | $544,561 |
| Value of corrective distributions | 2020-12-31 | $18,125 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-12-31 | $52,872 |
| 2019 : DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total plan liabilities at end of year | 2019-12-31 | $116,396 |
| Total plan liabilities at beginning of year | 2019-12-31 | $47,150 |
| Total income from all sources | 2019-12-31 | $1,002,033 |
| Expenses. Total of all expenses incurred | 2019-12-31 | $956,493 |
| Benefits paid (including direct rollovers) | 2019-12-31 | $527,860 |
| Total plan assets at end of year | 2019-12-31 | $212,692 |
| Total plan assets at beginning of year | 2019-12-31 | $97,906 |
| Value of fidelity bond covering the plan | 2019-12-31 | $50,000 |
| Total contributions received or receivable from participants | 2019-12-31 | $266,574 |
| Expenses. Other expenses not covered elsewhere | 2019-12-31 | $346,654 |
| Contributions received from other sources (not participants or employers) | 2019-12-31 | $4,896 |
| Other income received | 2019-12-31 | $400 |
| Net income (gross income less expenses) | 2019-12-31 | $45,540 |
| Net plan assets at end of year (total assets less liabilities) | 2019-12-31 | $96,296 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-12-31 | $50,756 |
| Total contributions received or receivable from employer(s) | 2019-12-31 | $730,163 |
| Value of corrective distributions | 2019-12-31 | $25,374 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-12-31 | $56,605 |
| 2018 : DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2018 401k financial data |
|---|
| Total plan liabilities at end of year | 2018-12-31 | $47,150 |
| Total plan liabilities at beginning of year | 2018-12-31 | $61,670 |
| Total income from all sources | 2018-12-31 | $262,873 |
| Expenses. Total of all expenses incurred | 2018-12-31 | $220,164 |
| Benefits paid (including direct rollovers) | 2018-12-31 | $109,702 |
| Total plan assets at end of year | 2018-12-31 | $97,906 |
| Total plan assets at beginning of year | 2018-12-31 | $69,717 |
| Value of fidelity bond covering the plan | 2018-12-31 | $50,000 |
| Total contributions received or receivable from participants | 2018-12-31 | $70,774 |
| Expenses. Other expenses not covered elsewhere | 2018-12-31 | $93,883 |
| Other income received | 2018-12-31 | $72 |
| Net income (gross income less expenses) | 2018-12-31 | $42,709 |
| Net plan assets at end of year (total assets less liabilities) | 2018-12-31 | $50,756 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-12-31 | $8,047 |
| Total contributions received or receivable from employer(s) | 2018-12-31 | $192,027 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2018-12-31 | $16,579 |
| 2022: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – Trust | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement - Trust | Yes |
| 2021: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – Trust | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement - Trust | Yes |
| 2020: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – Trust | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement - Trust | Yes |
| 2019: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – Trust | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement - Trust | Yes |
| 2018: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – Trust | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement - Trust | Yes |
| 2017: DAVID G. HORSEY & SONS, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | First time form 5500 has been submitted | Yes |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – Trust | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement - Trust | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 761076 |
| Policy instance | 2 |
| Insurance contract or identification number | 761076 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $62,640 | | Total amount of fees paid to insurance company | USD $2,916 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,320 | | Amount paid for insurance broker fees | 1663 | | Additional information about fees paid to insurance broker | COMMISSION | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500295 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500295 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 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 | | 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 $-1,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 909-14-77773 |
| Policy instance | 2 |
| Insurance contract or identification number | 909-14-77773 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,704 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,720 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500295 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500295 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 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 | | 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 $284,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 909-14-B1773 |
| Policy instance | 2 |
| Insurance contract or identification number | 909-14-B1773 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $655 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,824 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $362 | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500295 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500295 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 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 | | 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 $306,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 91 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 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 | | 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 $289,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 99091477773 000 |
| Policy instance | 2 |
| Insurance contract or identification number | 99091477773 000 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,608 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,304 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 83 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | 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 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 | | 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 $75,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9091477773 001 |
| Policy instance | 3 |
| Insurance contract or identification number | 9091477773 001 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $251 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $251 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 99091477773 000 |
| Policy instance | 2 |
| Insurance contract or identification number | 99091477773 000 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,200 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,209 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,200 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 99091477773 000 |
| Policy instance | 2 |
| Insurance contract or identification number | 99091477773 000 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $3,593 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 74 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | 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 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 | | 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 $220,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9091477773 001 |
| Policy instance | 3 |
| Insurance contract or identification number | 9091477773 001 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $566 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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