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BURTON SNOWBOARDS WELFARE BENEFIT PLAN 401k Plan overview

Plan NameBURTON SNOWBOARDS WELFARE BENEFIT PLAN
Plan identification number 505

BURTON SNOWBOARDS WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

THE BURTON CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:THE BURTON CORPORATION
Employer identification number (EIN):030269736
NAIC Classification:339900

Additional information about THE BURTON CORPORATION

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 1990-01-22
Company Identification Number: 601226151
Legal Registered Office Address: 1030 14TH PL W

KIRKLAND
United States of America (USA)
98033

More information about THE BURTON CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BURTON SNOWBOARDS WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052022-03-01
5052021-03-01
5052020-03-01
5052019-03-01
5052018-03-01

Plan Statistics for BURTON SNOWBOARDS WELFARE BENEFIT PLAN

401k plan membership statisitcs for BURTON SNOWBOARDS WELFARE BENEFIT PLAN

Measure Date Value
2022: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01456
Total number of active participants reported on line 7a of the Form 55002022-03-01449
Number of retired or separated participants receiving benefits2022-03-014
Number of other retired or separated participants entitled to future benefits2022-03-018
Total of all active and inactive participants2022-03-01461
2021: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-03-01433
Total number of active participants reported on line 7a of the Form 55002021-03-01419
Number of retired or separated participants receiving benefits2021-03-017
Number of other retired or separated participants entitled to future benefits2021-03-013
Total of all active and inactive participants2021-03-01429
2020: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01514
Total number of active participants reported on line 7a of the Form 55002020-03-01428
Number of retired or separated participants receiving benefits2020-03-015
Number of other retired or separated participants entitled to future benefits2020-03-01135
Total of all active and inactive participants2020-03-01568
2019: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01472
Total number of active participants reported on line 7a of the Form 55002019-03-01502
Number of retired or separated participants receiving benefits2019-03-014
Number of other retired or separated participants entitled to future benefits2019-03-016
Total of all active and inactive participants2019-03-01512
2018: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01444
Total number of active participants reported on line 7a of the Form 55002018-03-01462
Number of retired or separated participants receiving benefits2018-03-015
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01467

Form 5500 Responses for BURTON SNOWBOARDS WELFARE BENEFIT PLAN

2022: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)No
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan funding arrangement – General assets of the sponsorYes
2022-03-01Plan benefit arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – General assets of the sponsorYes
2021: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-03-01Type of plan entitySingle employer plan
2021-03-01Submission has been amendedNo
2021-03-01This submission is the final filingNo
2021-03-01This return/report is a short plan year return/report (less than 12 months)No
2021-03-01Plan is a collectively bargained planNo
2021-03-01Plan funding arrangement – InsuranceYes
2021-03-01Plan funding arrangement – General assets of the sponsorYes
2021-03-01Plan benefit arrangement – InsuranceYes
2021-03-01Plan benefit arrangement – General assets of the sponsorYes
2020: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Submission has been amendedNo
2020-03-01This submission is the final filingNo
2020-03-01This return/report is a short plan year return/report (less than 12 months)No
2020-03-01Plan is a collectively bargained planNo
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan funding arrangement – General assets of the sponsorYes
2020-03-01Plan benefit arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – General assets of the sponsorYes
2019: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Submission has been amendedNo
2019-03-01This submission is the final filingNo
2019-03-01This return/report is a short plan year return/report (less than 12 months)No
2019-03-01Plan is a collectively bargained planNo
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan funding arrangement – General assets of the sponsorYes
2019-03-01Plan benefit arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – General assets of the sponsorYes
2018: BURTON SNOWBOARDS WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01First time form 5500 has been submittedYes
2018-03-01Submission has been amendedNo
2018-03-01This submission is the final filingNo
2018-03-01This return/report is a short plan year return/report (less than 12 months)No
2018-03-01Plan is a collectively bargained planNo
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan funding arrangement – General assets of the sponsorYes
2018-03-01Plan benefit arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5950799
Policy instance 3
Insurance contract or identification number5950799
Number of Individuals Covered571
Insurance policy start date2022-07-01
Insurance policy end date2023-02-28
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5369302*
Policy instance 2
Insurance contract or identification number5369302*
Number of Individuals Covered110
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $8,469
Total amount of fees paid to insurance companyUSD $2,853
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT, HOSPITAL INDEMNITY
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 $30,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,469
Amount paid for insurance broker fees117
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969456*
Policy instance 1
Insurance contract or identification numberFLX969456*
Number of Individuals Covered449
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $-47
Total amount of fees paid to insurance companyUSD $3,287
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $143,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $-47
Amount paid for insurance broker fees2541
Additional information about fees paid to insurance brokerSERVICE FEE
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5369302*
Policy instance 2
Insurance contract or identification number5369302*
Number of Individuals Covered275
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $927
Total amount of fees paid to insurance companyUSD $4,319
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT, HOSPITAL INDEMNITY
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 $77,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3909
Additional information about fees paid to insurance brokerTPA ADMIN FEES
Insurance broker organization code?5
Commission paid to Insurance BrokerUSD $927
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969456*
Policy instance 1
Insurance contract or identification numberFLX969456*
Number of Individuals Covered419
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,009
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $165,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees6407
Additional information about fees paid to insurance brokerSALES & SERVICE FEE
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5369302*
Policy instance 2
Insurance contract or identification number5369302*
Number of Individuals Covered311
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $15,138
Total amount of fees paid to insurance companyUSD $6,616
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, ACCIDENT, HOSPITAL INDEMNITY
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 $91,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,138
Amount paid for insurance broker fees124
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969456*
Policy instance 1
Insurance contract or identification numberFLX969456*
Number of Individuals Covered428
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,576
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $171,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees8576
Additional information about fees paid to insurance brokerSALES & SERVICE FEE
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5369302
Policy instance 2
Insurance contract or identification number5369302
Number of Individuals Covered418
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,975
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $78,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3914
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?5
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10220632*
Policy instance 1
Insurance contract or identification number10220632*
Number of Individuals Covered0
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,564
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $171,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees8564
Additional information about fees paid to insurance brokerTPA FEE
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05369302
Policy instance 2
Insurance contract or identification numberTS05369302
Number of Individuals Covered1226
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,005
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 $58,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2913
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?5
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10220632*
Policy instance 1
Insurance contract or identification number10220632*
Number of Individuals Covered467
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $930
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $129,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees930
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3

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