401k Plan data: CHENEY BROTHERS OFS MEDICAL & DENTAL plan

CHENEY BROTHERS OFS MEDICAL & DENTAL 401k Plan overview

Plan Name	CHENEY BROTHERS OFS MEDICAL & DENTAL
Plan identification number	501

CHENEY BROTHERS OFS MEDICAL & DENTAL Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental

401k Sponsoring company profile

CHENEY BROTHERS OFS has sponsored the creation of one or more 401k plans.

Company Name: CHENEY BROTHERS OFS

Employer identification number (EIN): 800249585

NAIC Classification: 424400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHENEY BROTHERS OFS MEDICAL & DENTAL

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-07-01 MICHAEL SULLIVAN MICHAEL SULLIVAN 2016-07-01
501 2014-07-01 MICHAEL SULLIVAN MICHAEL SULLIVAN 2016-07-18
501 2013-07-01 MICHAEL SULLIVAN MICHAEL SULLIVAN 2015-03-10

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2014-07-01	MICHAEL SULLIVAN	MICHAEL SULLIVAN	2016-07-01
501	2014-07-01	MICHAEL SULLIVAN	MICHAEL SULLIVAN	2016-07-18
501	2013-07-01	MICHAEL SULLIVAN	MICHAEL SULLIVAN	2015-03-10

Plan Statistics for CHENEY BROTHERS OFS MEDICAL & DENTAL

401k plan membership statisitcs for CHENEY BROTHERS OFS MEDICAL & DENTAL

Measure Date Value
2014: CHENEY BROTHERS OFS MEDICAL & DENTAL 2014 401k membership
Total participants, beginning-of-year 2014-07-01 141
Total number of active participants reported on line 7a of the Form 5500 2014-07-01 122
Total of all active and inactive participants 2014-07-01 122
Total participants 2014-07-01 122
2013: CHENEY BROTHERS OFS MEDICAL & DENTAL 2013 401k membership
Total participants, beginning-of-year 2013-07-01 114
Total number of active participants reported on line 7a of the Form 5500 2013-07-01 141
Total of all active and inactive participants 2013-07-01 141
Total participants 2013-07-01 141

Measure	Date	Value
2014: CHENEY BROTHERS OFS MEDICAL & DENTAL 2014 401k membership
Total participants, beginning-of-year	2014-07-01	141
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	122
Total of all active and inactive participants	2014-07-01	122
Total participants	2014-07-01	122
2013: CHENEY BROTHERS OFS MEDICAL & DENTAL 2013 401k membership
Total participants, beginning-of-year	2013-07-01	114
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	141
Total of all active and inactive participants	2013-07-01	141
Total participants	2013-07-01	141

Form 5500 Responses for CHENEY BROTHERS OFS MEDICAL & DENTAL

2014: CHENEY BROTHERS OFS MEDICAL & DENTAL 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Submission has been amended	No
2014-07-01	This submission is the final filing	No
2014-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-07-01	Plan is a collectively bargained plan	No
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: CHENEY BROTHERS OFS MEDICAL & DENTAL 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	First time form 5500 has been submitted	Yes
2013-07-01	Submission has been amended	No
2013-07-01	This submission is the final filing	No
2013-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-07-01	Plan is a collectively bargained plan	No
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334811

Policy instance

Insurance contract or identification number	3334811
Number of Individuals Covered	122
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $4,153
Total amount of fees paid to insurance company	USD $916
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $74,796
Amount paid for insurance broker fees	916
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker name	BROWN & BROWN OF FLORIDA

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3334811

Policy instance

Insurance contract or identification number	3334811
Number of Individuals Covered	141
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $2,452
Total amount of fees paid to insurance company	USD $44,671
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
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 $918,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,452
Amount paid for insurance broker fees	44671
Additional information about fees paid to insurance broker	BENEFIT ADVISOR PAYMENTS
Insurance broker organization code?	3
Insurance broker name	BROWN & BROWN-PINELLAS FLORIDA

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Company Name:	CHENEY BROTHERS OFS
Employer identification number (EIN):	800249585
NAIC Classification:	424400