FIELDSTONE PROPERTIES I LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN
401k plan membership statisitcs for FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2022: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 209 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 209 |
| 2021: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 247 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 216 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
| Total of all active and inactive participants | 2021-06-01 | 216 |
| 2020: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-31 | 266 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-31 | 247 |
| Number of retired or separated participants receiving benefits | 2020-12-31 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-31 | 0 |
| Total of all active and inactive participants | 2020-12-31 | 247 |
| Total participants, beginning-of-year | 2020-01-01 | 266 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 247 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| 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 | 247 |
| 2019: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 266 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 266 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| 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 | 266 |
| 2018: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 248 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 266 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 266 |
| 2017: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 251 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 248 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 248 |
| 2016: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 251 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 251 |
| 2015: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 180 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 180 |
| 2014: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 174 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 236 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 236 |
| 2013: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 174 |
| Total of all active and inactive participants | 2013-01-01 | 174 |
| 2012: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 183 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 2 |
| Total of all active and inactive participants | 2012-06-01 | 185 |
| 2022: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2020 form 5500 responses |
|---|
| 2020-12-31 | Type of plan entity | Single employer plan |
| 2020-12-31 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-12-31 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-31 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-31 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: FIELDSTONE PROPERTIES I, LLC HEALTH INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | First time form 5500 has been submitted | Yes |
| 2012-06-01 | Submission has been amended | Yes |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 805564G |
| Policy instance | 5 |
| Insurance contract or identification number | 805564G | | Number of Individuals Covered | 209 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OTHER (SPECIFY) ACCIDENTAL DEATH & | | Welfare Benefit Premiums Paid to Carrier | USD $31,952 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $14,124 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $365,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,124 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $4,233 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,233 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $2,232 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,488 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | MGTF |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $9,630 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $197,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,630 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $9,330 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $178,324 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,330 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $2,453 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,279 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | MGTF |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $4,461 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,461 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $16,811 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $395,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,811 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 805564G |
| Policy instance | 5 |
| Insurance contract or identification number | 805564G | | Number of Individuals Covered | 216 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OTHER (SPECIFY) ACCIDENTAL DEATH & | | Welfare Benefit Premiums Paid to Carrier | USD $42,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $4,495 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $89,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,495 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $589 | | Total amount of fees paid to insurance company | USD $294 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,409 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $589 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 294 | | Additional information about fees paid to insurance broker | MGTF |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $1,642 | | Dental Insurance Welfare Benefit | Yes | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,642 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Total amount of fees paid to insurance company | USD $7,952 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $160,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7952 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 805564G |
| Policy instance | 5 |
| Insurance contract or identification number | 805564G | | Number of Individuals Covered | 219 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OTHER (SPECIFY) ACCIDENTAL DEATH & | | Welfare Benefit Premiums Paid to Carrier | USD $11,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10068531001 |
| Policy instance | 6 |
| Insurance contract or identification number | 10068531001 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-12-31 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $2 | | Total amount of fees paid to insurance company | USD $1 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25 | | 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 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10068531001 |
| Policy instance | 6 |
| Insurance contract or identification number | 10068531001 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4 | | Total amount of fees paid to insurance company | USD $2 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 805564G |
| Policy instance | 5 |
| Insurance contract or identification number | 805564G | | Number of Individuals Covered | 219 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OTHER (SPECIFY) ACCIDENTAL DEATH & | | Welfare Benefit Premiums Paid to Carrier | USD $16,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $11,182 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $221,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 11182 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,300 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,300 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $823 | | Total amount of fees paid to insurance company | USD $412 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,972 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $823 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 412 | | Additional information about fees paid to insurance broker | MGTF |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $6,195 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $125,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,195 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $11,820 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $244,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,820 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $1,714 | | Total amount of fees paid to insurance company | USD $857 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,714 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 857 | | Additional information about fees paid to insurance broker | MGTF |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $4,514 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,514 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,069 | | Total amount of fees paid to insurance company | USD $18,282 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $419,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,069 | | Amount paid for insurance broker fees | 18282 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0225932 |
| Policy instance | 5 |
| Insurance contract or identification number | 0225932 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $6,697 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | OTHER (SPECIFY) ACCIDENTAL DEATH & | | Welfare Benefit Premiums Paid to Carrier | USD $38,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,797 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10068531001 |
| Policy instance | 6 |
| Insurance contract or identification number | 10068531001 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $30 | | Total amount of fees paid to insurance company | USD $15 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 $30 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 15 |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $14,640 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $322,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,260 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,241 | | Total amount of fees paid to insurance company | USD $620 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $717 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 620 | | Additional information about fees paid to insurance broker | MGTF |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 3 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $4,491 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,458 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00622621 |
| Policy instance | 4 |
| Insurance contract or identification number | 00622621 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $9,855 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $232,069 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,855 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0225932-0225932 |
| Policy instance | 2 |
| Insurance contract or identification number | 0225932-0225932 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $8,851 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $894,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,438 | | Additional information about fees paid to insurance broker | HEALTH (OTHER THAN DENTAL OR VISION | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INSURANCE AND FINANCIAL |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 284863 |
| Policy instance | 3 |
| Insurance contract or identification number | 284863 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $7,486 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,339 | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INS AGENCY & FINANCE |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10064321001 |
| Policy instance | 4 |
| Insurance contract or identification number | 10064321001 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $2,733 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,163 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,989 | | Additional information about fees paid to insurance broker | COMM | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INS & FINACNCIAL SERVI |
|
| DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 ) |
| Policy contract number | 09499 |
| Policy instance | 5 |
| Insurance contract or identification number | 09499 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $4,515 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,166 | | Insurance broker organization code? | 3 | | Insurance broker name | JACOB GOLDFARB & SIN INC |
|
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 24234 |
| Policy instance | 1 |
| Insurance contract or identification number | 24234 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $18,180 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $293,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,180 | | Insurance broker organization code? | 3 | | Insurance broker name | JACOB SILVERMAN |
|
