401k Plan data: EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN plan

EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN
Plan identification number	501

EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare 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)

401k Sponsoring company profile

EMPIRE TELEPHONE CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: EMPIRE TELEPHONE CORPORATION

Employer identification number (EIN): 160594870

NAIC Classification: 517000

Additional information about EMPIRE TELEPHONE CORPORATION

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1919-02-15

Company Identification Number: 26306

Legal Registered Office Address: 10 GREENRIDGE DR
PO BOX 349
PAINTED POST
United States of America (USA)
14870

More information about EMPIRE TELEPHONE CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01

Plan Statistics for EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2022: EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 168
Number of retired or separated participants receiving benefits 2022-01-01 3
Number of other retired or separated participants entitled to future benefits 2022-01-01 3
Total of all active and inactive participants 2022-01-01 174

Measure	Date	Value
2022: EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	168
Number of retired or separated participants receiving benefits	2022-01-01	3
Number of other retired or separated participants entitled to future benefits	2022-01-01	3
Total of all active and inactive participants	2022-01-01	174

Form 5500 Responses for EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN

2022: EMPIRE TELEPHONE CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00008548

Policy instance

Insurance contract or identification number	00008548
Number of Individuals Covered	123
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $71,911
Health 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 $71,911
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00355010

Policy instance

Insurance contract or identification number	00355010
Number of Individuals Covered	147
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,551
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $174,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,428
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

481014

Policy instance

Insurance contract or identification number	481014
Number of Individuals Covered	11
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,195
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,195
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

936003

Policy instance

Insurance contract or identification number	936003
Number of Individuals Covered	19
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,474
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $9,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,474
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

447065

Policy instance

Insurance contract or identification number	447065
Number of Individuals Covered	32
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,197
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,197
Insurance broker organization code?	3

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Company Name:	EMPIRE TELEPHONE CORPORATION
Employer identification number (EIN):	160594870
NAIC Classification:	517000

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1919-02-15
Company Identification Number:	26306
Legal Registered Office Address:	10 GREENRIDGE DR PO BOX 349 PAINTED POST United States of America (USA) 14870