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DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameDRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN
Plan identification number 502

DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE 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)
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

DRA ENERGY OPERATIONS CO. has sponsored the creation of one or more 401k plans.

Company Name:DRA ENERGY OPERATIONS CO.
Employer identification number (EIN):205161001
NAIC Classification:237990
NAIC Description:Other Heavy and Civil Engineering Construction

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01MELISSA STRUZZI2023-03-16
5022021-01-01MELISSA STRUZZI2022-08-22
5022020-01-01MELISSA STRUZZI2021-08-23
5022019-01-01MELISSA STRUZZI2020-09-29
5022018-01-01MELISSA STRUZZI2019-10-08
5022018-01-01MELISSA STRUZZI2020-03-02
5022018-01-01MELISSA STRUZZI2020-10-05
5022017-01-01
5022017-01-01MELISSA STRUZZI2020-01-08
5022016-01-01MELISSA STRUZZI ENGLESBERG
5022016-01-01MELISSA STRUZZI2020-01-08
5022015-01-01MELISSA STRUZZI ENGLESBERG
5022014-01-01MELISSA STRUZZI ENGLESBERG

Plan Statistics for DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN

Measure Date Value
2022: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01127
Total number of active participants reported on line 7a of the Form 55002022-01-0110
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-0110
Number of employers contributing to the scheme2022-01-010
2021: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01127
Total number of active participants reported on line 7a of the Form 55002021-01-01127
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01127
Number of employers contributing to the scheme2021-01-010
2020: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01156
Total number of active participants reported on line 7a of the Form 55002020-01-01152
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01152
Number of employers contributing to the scheme2020-01-010
2019: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01136
Total number of active participants reported on line 7a of the Form 55002019-01-01156
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01156
Number of employers contributing to the scheme2019-01-010
2018: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01146
Total number of active participants reported on line 7a of the Form 55002018-01-01136
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01136
Number of employers contributing to the scheme2018-01-010
2017: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01233
Total number of active participants reported on line 7a of the Form 55002017-01-01233
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01233
Number of employers contributing to the scheme2017-01-010
2016: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01209
Total number of active participants reported on line 7a of the Form 55002016-01-01233
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01233
Number of employers contributing to the scheme2016-01-010
2015: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01221
Total number of active participants reported on line 7a of the Form 55002015-01-01209
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01209
2014: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01100
Total number of active participants reported on line 7a of the Form 55002014-01-01221
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01221

Form 5500 Responses for DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN

2022: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: DRA ENERGY OPERATIONS CO. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01First time form 5500 has been submittedYes
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00617538
Policy instance 5
Insurance contract or identification numberG00617538
Number of Individuals Covered4
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,875
Total amount of fees paid to insurance companyUSD $1,019
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $25,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,875
Amount paid for insurance broker fees1019
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921932-099
Policy instance 4
Insurance contract or identification number921932-099
Number of Individuals Covered21
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,239
Total amount of fees paid to insurance companyUSD $1,191
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,239
Amount paid for insurance broker fees1191
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4902094
Policy instance 3
Insurance contract or identification numberE4902094
Number of Individuals Covered7
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $732
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $12,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $339
Amount paid for insurance broker fees0
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number99687
Policy instance 2
Insurance contract or identification number99687
Number of Individuals Covered21
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,992
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $461,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,992
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered9
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $71
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered126
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $244
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $244
Amount paid for insurance broker fees0
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number99687
Policy instance 2
Insurance contract or identification number99687
Number of Individuals Covered260
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $33,888
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,282,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,888
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4902094
Policy instance 3
Insurance contract or identification numberE4902094
Number of Individuals Covered15
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,245
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $20,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $615
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921932-099
Policy instance 4
Insurance contract or identification number921932-099
Number of Individuals Covered286
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,835
Total amount of fees paid to insurance companyUSD $5,182
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $77,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,835
Amount paid for insurance broker fees5182
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00617538
Policy instance 5
Insurance contract or identification numberG00617538
Number of Individuals Covered132
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,937
Total amount of fees paid to insurance companyUSD $2,935
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $73,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,937
Amount paid for insurance broker fees2935
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00617538
Policy instance 5
Insurance contract or identification numberG00617538
Number of Individuals Covered136
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,394
Total amount of fees paid to insurance companyUSD $2,628
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $68,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,394
Amount paid for insurance broker fees2628
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered134
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $250
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $250
Amount paid for insurance broker fees0
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number99687
Policy instance 2
Insurance contract or identification number99687
Number of Individuals Covered290
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $36,552
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,607,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,552
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4902094
Policy instance 3
Insurance contract or identification numberE4902094
Number of Individuals Covered16
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,651
Total amount of fees paid to insurance companyUSD $47
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $21,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $765
Amount paid for insurance broker fees36
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921932-099
Policy instance 4
Insurance contract or identification number921932-099
Number of Individuals Covered351
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,425
Total amount of fees paid to insurance companyUSD $5,352
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,425
Amount paid for insurance broker fees5352
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered152
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $278
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $278
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG00617538
Policy instance 5
Insurance contract or identification numberG00617538
Number of Individuals Covered156
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,525
Total amount of fees paid to insurance companyUSD $2,367
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $78,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,525
Amount paid for insurance broker fees2367
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number921932-099
Policy instance 4
Insurance contract or identification number921932-099
Number of Individuals Covered349
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $9,063
Total amount of fees paid to insurance companyUSD $2,499
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $90,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $9,063
Amount paid for insurance broker fees2499
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4902094
Policy instance 3
Insurance contract or identification numberE4902094
Number of Individuals Covered18
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,394
Total amount of fees paid to insurance companyUSD $831
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $22,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,863
Amount paid for insurance broker fees718
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number99687
Policy instance 2
Insurance contract or identification number99687
Number of Individuals Covered317
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $43,008
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,671,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,008
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA-LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605458
Policy instance 6
Insurance contract or identification numberSGM605458
Number of Individuals Covered136
Insurance policy start date2018-08-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,815
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $45,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $6,815
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605458
Policy instance 5
Insurance contract or identification numberSGM605458
Number of Individuals Covered136
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $13,855
Total amount of fees paid to insurance companyUSD $4,131
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
Welfare Benefit Premiums Paid to CarrierUSD $92,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $13,855
Amount paid for insurance broker fees4131
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05940764
Policy instance 4
Insurance contract or identification numberTM05940764
Number of Individuals Covered417
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,733
Total amount of fees paid to insurance companyUSD $1,315
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $88,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,733
Amount paid for insurance broker fees1304
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4902094
Policy instance 3
Insurance contract or identification numberE4902094
Number of Individuals Covered17
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,180
Total amount of fees paid to insurance companyUSD $2,230
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $15,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,193
Amount paid for insurance broker fees1818
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number99687
Policy instance 2
Insurance contract or identification number99687
Number of Individuals Covered335
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $40,968
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,663,386
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,968
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605458
Policy instance 1
Insurance contract or identification numberSGM605458
Number of Individuals Covered136
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 2
Insurance contract or identification number1729
Number of Individuals Covered143
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $307
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $307
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605552
Policy instance 3
Insurance contract or identification numberSGD605552
Number of Individuals Covered136
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605551
Policy instance 4
Insurance contract or identification numberSGD605551
Number of Individuals Covered136
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4905527
Policy instance 5
Insurance contract or identification numberE4905527
Number of Individuals Covered1
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $337
Total amount of fees paid to insurance companyUSD $96
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91
Amount paid for insurance broker fees78
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5940764
Policy instance 6
Insurance contract or identification number5940764
Number of Individuals Covered417
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,733
Total amount of fees paid to insurance companyUSD $1,315
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $88,325
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,733
Amount paid for insurance broker fees1304
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK603751
Policy instance 7
Insurance contract or identification numberSOK603751
Number of Individuals Covered136
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered143
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $307
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $307
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605458
Policy instance 4
Insurance contract or identification numberSGM605458
Number of Individuals Covered233
Insurance policy start date2016-08-01
Insurance policy end date2017-07-31
Total amount of commissions paid to insurance brokerUSD $20,918
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $139,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 2
Insurance contract or identification number1729
Number of Individuals Covered185
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $427
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $427
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM605458
Policy instance 1
Insurance contract or identification numberSGM605458
Number of Individuals Covered233
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605552
Policy instance 3
Insurance contract or identification numberSGD605552
Number of Individuals Covered233
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD605551
Policy instance 4
Insurance contract or identification numberSGD605551
Number of Individuals Covered233
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK603751
Policy instance 5
Insurance contract or identification numberSOK603751
Number of Individuals Covered233
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered185
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $427
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
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 numberTM05940764
Policy instance 2
Insurance contract or identification numberTM05940764
Number of Individuals Covered579
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,284
Total amount of fees paid to insurance companyUSD $2,222
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $115,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract numberV2277
Policy instance 3
Insurance contract or identification numberV2277
Number of Individuals Covered13
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $978
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $13,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberSGM605458
Policy instance 2
Insurance contract or identification numberSGM605458
Number of Individuals Covered209
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $22,584
Total amount of fees paid to insurance companyUSD $5,120
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 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 $150,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $22,584
Amount paid for insurance broker fees5120
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered211
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $436
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $436
Insurance broker organization code?3
Insurance broker nameGALLAGER BENEFIT SERVICES, INC.
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number1729
Policy instance 1
Insurance contract or identification number1729
Number of Individuals Covered216
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $465
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $465
Insurance broker organization code?3
Insurance broker nameGALLAGER BENEFIT SERVICES, INC.
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberSGM605458
Policy instance 3
Insurance contract or identification numberSGM605458
Number of Individuals Covered221
Insurance policy start date2014-08-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $7,367
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 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 $49,112
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,367
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10094075
Policy instance 2
Insurance contract or identification number10094075
Number of Individuals Covered221
Insurance policy start date2014-01-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $5,046
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 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 $87,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,046
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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