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TRAVEL ACCIDENT INSURANCE 401k Plan overview

Plan NameTRAVEL ACCIDENT INSURANCE
Plan identification number 505

TRAVEL ACCIDENT INSURANCE Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Temporary disability (accident and sickness)
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

RIDGEWOOD SAVINGS BANK has sponsored the creation of one or more 401k plans.

Company Name:RIDGEWOOD SAVINGS BANK
Employer identification number (EIN):111241830
NAIC Classification:522120
NAIC Description:Savings Institutions

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TRAVEL ACCIDENT INSURANCE

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052022-04-22
5052021-04-22
5052020-04-22
5052019-04-22
5052018-04-22
5052017-04-22LAURA PETERS LAURA PETERS2018-11-20
5052016-04-22LAURA PETERS LAURA PETERS2017-09-01
5052015-04-22LAURA PETERS LAURA PETERS2016-11-18
5052014-04-22LAURA PETERS LAURA PETERS2015-07-31
5052013-04-22LAURA PETERS LAURA PETERS2014-11-21
5052012-04-22LAURA PETERS LAURA PETERS2013-11-21
5052011-04-22NORMAN MCNAMEE
5052009-04-22NORMAN MCNAMEE

Plan Statistics for TRAVEL ACCIDENT INSURANCE

401k plan membership statisitcs for TRAVEL ACCIDENT INSURANCE

Measure Date Value
2022: TRAVEL ACCIDENT INSURANCE 2022 401k membership
Total participants, beginning-of-year2022-04-22543
Total number of active participants reported on line 7a of the Form 55002022-04-22556
Total of all active and inactive participants2022-04-22556
Total participants2022-04-22556
2021: TRAVEL ACCIDENT INSURANCE 2021 401k membership
Total participants, beginning-of-year2021-04-22575
Total number of active participants reported on line 7a of the Form 55002021-04-22543
Total of all active and inactive participants2021-04-22543
Total participants2021-04-22543
2020: TRAVEL ACCIDENT INSURANCE 2020 401k membership
Total participants, beginning-of-year2020-04-22603
Total number of active participants reported on line 7a of the Form 55002020-04-22575
Total of all active and inactive participants2020-04-22575
Total participants2020-04-22575
2019: TRAVEL ACCIDENT INSURANCE 2019 401k membership
Total participants, beginning-of-year2019-04-22635
Total number of active participants reported on line 7a of the Form 55002019-04-22603
Total of all active and inactive participants2019-04-22603
Total participants2019-04-22603
2018: TRAVEL ACCIDENT INSURANCE 2018 401k membership
Total participants, beginning-of-year2018-04-22665
Total number of active participants reported on line 7a of the Form 55002018-04-22635
Total of all active and inactive participants2018-04-22635
Total participants2018-04-22635
2017: TRAVEL ACCIDENT INSURANCE 2017 401k membership
Total participants, beginning-of-year2017-04-22675
Total number of active participants reported on line 7a of the Form 55002017-04-22665
Total of all active and inactive participants2017-04-22665
Total participants2017-04-22665
2016: TRAVEL ACCIDENT INSURANCE 2016 401k membership
Total participants, beginning-of-year2016-04-22697
Total number of active participants reported on line 7a of the Form 55002016-04-22675
Total of all active and inactive participants2016-04-22675
Total participants2016-04-22675
2015: TRAVEL ACCIDENT INSURANCE 2015 401k membership
Total participants, beginning-of-year2015-04-22692
Total number of active participants reported on line 7a of the Form 55002015-04-22697
Total of all active and inactive participants2015-04-22697
Total participants2015-04-22697
2014: TRAVEL ACCIDENT INSURANCE 2014 401k membership
Total participants, beginning-of-year2014-04-22739
Total number of active participants reported on line 7a of the Form 55002014-04-22692
Total of all active and inactive participants2014-04-22692
Total participants2014-04-22692
2013: TRAVEL ACCIDENT INSURANCE 2013 401k membership
Total participants, beginning-of-year2013-04-22739
Total number of active participants reported on line 7a of the Form 55002013-04-22739
Total of all active and inactive participants2013-04-22739
Total participants2013-04-22739
2012: TRAVEL ACCIDENT INSURANCE 2012 401k membership
Total participants, beginning-of-year2012-04-227
Total number of active participants reported on line 7a of the Form 55002012-04-227
Total of all active and inactive participants2012-04-227
Total participants2012-04-227
2011: TRAVEL ACCIDENT INSURANCE 2011 401k membership
Total participants, beginning-of-year2011-04-22764
Total number of active participants reported on line 7a of the Form 55002011-04-22766
Total of all active and inactive participants2011-04-22766
Total participants2011-04-22766
2009: TRAVEL ACCIDENT INSURANCE 2009 401k membership
Total participants, beginning-of-year2009-04-22803
Total number of active participants reported on line 7a of the Form 55002009-04-22791
Total of all active and inactive participants2009-04-22791
Total participants2009-04-22791

Form 5500 Responses for TRAVEL ACCIDENT INSURANCE

2022: TRAVEL ACCIDENT INSURANCE 2022 form 5500 responses
2022-04-22Type of plan entitySingle employer plan
2022-04-22Submission has been amendedNo
2022-04-22This submission is the final filingNo
2022-04-22This return/report is a short plan year return/report (less than 12 months)No
2022-04-22Plan is a collectively bargained planNo
2022-04-22Plan funding arrangement – InsuranceYes
2022-04-22Plan benefit arrangement – InsuranceYes
2021: TRAVEL ACCIDENT INSURANCE 2021 form 5500 responses
2021-04-22Type of plan entitySingle employer plan
2021-04-22Submission has been amendedNo
2021-04-22This submission is the final filingNo
2021-04-22This return/report is a short plan year return/report (less than 12 months)No
2021-04-22Plan is a collectively bargained planNo
2021-04-22Plan funding arrangement – InsuranceYes
2021-04-22Plan benefit arrangement – InsuranceYes
2020: TRAVEL ACCIDENT INSURANCE 2020 form 5500 responses
2020-04-22Type of plan entitySingle employer plan
2020-04-22Submission has been amendedNo
2020-04-22This submission is the final filingNo
2020-04-22This return/report is a short plan year return/report (less than 12 months)No
2020-04-22Plan is a collectively bargained planNo
2020-04-22Plan funding arrangement – InsuranceYes
2020-04-22Plan benefit arrangement – InsuranceYes
2019: TRAVEL ACCIDENT INSURANCE 2019 form 5500 responses
2019-04-22Type of plan entitySingle employer plan
2019-04-22Submission has been amendedNo
2019-04-22This submission is the final filingNo
2019-04-22This return/report is a short plan year return/report (less than 12 months)No
2019-04-22Plan is a collectively bargained planNo
2019-04-22Plan funding arrangement – InsuranceYes
2019-04-22Plan benefit arrangement – InsuranceYes
2018: TRAVEL ACCIDENT INSURANCE 2018 form 5500 responses
2018-04-22Type of plan entitySingle employer plan
2018-04-22Submission has been amendedYes
2018-04-22This submission is the final filingNo
2018-04-22This return/report is a short plan year return/report (less than 12 months)No
2018-04-22Plan is a collectively bargained planNo
2018-04-22Plan funding arrangement – InsuranceYes
2018-04-22Plan benefit arrangement – InsuranceYes
2017: TRAVEL ACCIDENT INSURANCE 2017 form 5500 responses
2017-04-22Type of plan entitySingle employer plan
2017-04-22Submission has been amendedYes
2017-04-22This submission is the final filingNo
2017-04-22This return/report is a short plan year return/report (less than 12 months)No
2017-04-22Plan is a collectively bargained planNo
2017-04-22Plan funding arrangement – InsuranceYes
2017-04-22Plan benefit arrangement – InsuranceYes
2016: TRAVEL ACCIDENT INSURANCE 2016 form 5500 responses
2016-04-22Type of plan entitySingle employer plan
2016-04-22Submission has been amendedYes
2016-04-22This submission is the final filingNo
2016-04-22This return/report is a short plan year return/report (less than 12 months)No
2016-04-22Plan is a collectively bargained planNo
2016-04-22Plan funding arrangement – InsuranceYes
2016-04-22Plan benefit arrangement – InsuranceYes
2015: TRAVEL ACCIDENT INSURANCE 2015 form 5500 responses
2015-04-22Type of plan entitySingle employer plan
2015-04-22Submission has been amendedYes
2015-04-22This submission is the final filingNo
2015-04-22This return/report is a short plan year return/report (less than 12 months)No
2015-04-22Plan is a collectively bargained planNo
2015-04-22Plan funding arrangement – InsuranceYes
2015-04-22Plan benefit arrangement – InsuranceYes
2014: TRAVEL ACCIDENT INSURANCE 2014 form 5500 responses
2014-04-22Type of plan entitySingle employer plan
2014-04-22Submission has been amendedYes
2014-04-22This submission is the final filingNo
2014-04-22This return/report is a short plan year return/report (less than 12 months)No
2014-04-22Plan is a collectively bargained planNo
2014-04-22Plan funding arrangement – InsuranceYes
2014-04-22Plan benefit arrangement – InsuranceYes
2013: TRAVEL ACCIDENT INSURANCE 2013 form 5500 responses
2013-04-22Type of plan entitySingle employer plan
2013-04-22Submission has been amendedYes
2013-04-22This submission is the final filingNo
2013-04-22This return/report is a short plan year return/report (less than 12 months)No
2013-04-22Plan is a collectively bargained planNo
2013-04-22Plan funding arrangement – InsuranceYes
2013-04-22Plan benefit arrangement – InsuranceYes
2012: TRAVEL ACCIDENT INSURANCE 2012 form 5500 responses
2012-04-22Type of plan entitySingle employer plan
2012-04-22Submission has been amendedNo
2012-04-22This submission is the final filingNo
2012-04-22This return/report is a short plan year return/report (less than 12 months)No
2012-04-22Plan is a collectively bargained planNo
2012-04-22Plan funding arrangement – InsuranceYes
2012-04-22Plan benefit arrangement – InsuranceYes
2011: TRAVEL ACCIDENT INSURANCE 2011 form 5500 responses
2011-04-22Type of plan entitySingle employer plan
2011-04-22Submission has been amendedNo
2011-04-22This submission is the final filingNo
2011-04-22This return/report is a short plan year return/report (less than 12 months)No
2011-04-22Plan is a collectively bargained planNo
2011-04-22Plan funding arrangement – InsuranceYes
2011-04-22Plan benefit arrangement – InsuranceYes
2009: TRAVEL ACCIDENT INSURANCE 2009 form 5500 responses
2009-04-22Type of plan entitySingle employer plan
2009-04-22Submission has been amendedNo
2009-04-22This submission is the final filingNo
2009-04-22This return/report is a short plan year return/report (less than 12 months)No
2009-04-22Plan is a collectively bargained planNo
2009-04-22Plan funding arrangement – InsuranceYes
2009-04-22Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberN04248478
Policy instance 1
Insurance contract or identification numberN04248478
Number of Individuals Covered556
Insurance policy start date2022-04-22
Insurance policy end date2023-04-21
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberN04248478
Policy instance 1
Insurance contract or identification numberN04248478
Number of Individuals Covered543
Insurance policy start date2021-04-22
Insurance policy end date2022-04-21
Total amount of commissions paid to insurance brokerUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADDN04248478
Policy instance 1
Insurance contract or identification numberADDN04248478
Number of Individuals Covered575
Insurance policy start date2020-04-22
Insurance policy end date2021-04-21
Total amount of commissions paid to insurance brokerUSD $1,936
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $9,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,936
Additional information about fees paid to insurance brokerSERVICES
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered603
Insurance policy start date2019-04-22
Insurance policy end date2020-04-21
Total amount of commissions paid to insurance brokerUSD $646
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $646
Additional information about fees paid to insurance brokerSERVICES
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered635
Insurance policy start date2018-04-22
Insurance policy end date2019-04-21
Total amount of commissions paid to insurance brokerUSD $646
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $646
Additional information about fees paid to insurance brokerSERVICES
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered665
Insurance policy start date2017-04-22
Insurance policy end date2018-04-21
Total amount of commissions paid to insurance brokerUSD $646
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $646
Additional information about fees paid to insurance brokerSERVICES
Insurance broker nameMERCER HEALTH & BENEFITS
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered697
Insurance policy start date2015-04-22
Insurance policy end date2016-04-21
Total amount of commissions paid to insurance brokerUSD $672
Total amount of fees paid to insurance companyUSD $0
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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $672
Additional information about fees paid to insurance brokerSERVICES
Insurance broker nameMERCER HEALTH & BENEFITS
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered692
Insurance policy start date2014-04-22
Insurance policy end date2015-04-21
Total amount of commissions paid to insurance brokerUSD $672
Total amount of fees paid to insurance companyUSD $0
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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $672
Additional information about fees paid to insurance brokerSERVICES
Insurance broker nameMERCER HEALTH & BENEFITS
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered739
Insurance policy start date2013-04-22
Insurance policy end date2014-04-21
Total amount of commissions paid to insurance brokerUSD $656
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 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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedDEATH BENEFIT
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 $3,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $656
Additional information about fees paid to insurance brokerSERVICES
Insurance broker nameMERCER HEALTH & BENEFITS
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered761
Insurance policy start date2012-04-22
Insurance policy end date2013-04-21
Total amount of commissions paid to insurance brokerUSD $656
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedDEATH BENEFIT
Welfare Benefit Premiums Paid to CarrierUSD $3,277
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $656
Additional information about fees paid to insurance brokerSERVICES
Insurance broker nameMERCER HEALTH & BENEFITS
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04248478
Policy instance 1
Insurance contract or identification numberADD N04248478
Number of Individuals Covered231
Insurance policy start date2011-04-22
Insurance policy end date2012-04-21
Total amount of commissions paid to insurance brokerUSD $1,966
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedDEATH BENEFIT
Welfare Benefit Premiums Paid to CarrierUSD $9,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N0428478
Policy instance 1
Insurance contract or identification numberADD N0428478
Number of Individuals Covered764
Insurance policy start date2010-04-22
Insurance policy end date2011-04-21
Total amount of commissions paid to insurance brokerUSD $1,966
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedDEATH BENEFIT
Welfare Benefit Premiums Paid to CarrierUSD $9,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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