MASON DIXON FARMS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-09-01 | 16 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 17 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 0 |
| Total of all active and inactive participants | 2022-09-01 | 17 |
| 2021: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 23 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 16 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 16 |
| 2020: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 29 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 22 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 23 |
| 2019: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 31 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 28 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 29 |
| 2018: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 42 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 29 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 31 |
| Measure | Date | Value |
|---|
| 2023 : MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2023 401k financial data |
|---|
| Total plan liabilities at end of year | 2023-08-31 | $11,435 |
| Total plan liabilities at beginning of year | 2023-08-31 | $24,429 |
| Total income from all sources | 2023-08-31 | $281,186 |
| Expenses. Total of all expenses incurred | 2023-08-31 | $230,876 |
| Benefits paid (including direct rollovers) | 2023-08-31 | $106,876 |
| Total plan assets at end of year | 2023-08-31 | $120,362 |
| Total plan assets at beginning of year | 2023-08-31 | $83,046 |
| Value of fidelity bond covering the plan | 2023-08-31 | $206,000 |
| Total contributions received or receivable from participants | 2023-08-31 | $52,367 |
| Expenses. Other expenses not covered elsewhere | 2023-08-31 | $105,154 |
| Contributions received from other sources (not participants or employers) | 2023-08-31 | $0 |
| Other income received | 2023-08-31 | $1,024 |
| Net income (gross income less expenses) | 2023-08-31 | $50,310 |
| Net plan assets at end of year (total assets less liabilities) | 2023-08-31 | $108,927 |
| Net plan assets at beginning of year (total assets less liabilities) | 2023-08-31 | $58,617 |
| Total contributions received or receivable from employer(s) | 2023-08-31 | $227,795 |
| Value of corrective distributions | 2023-08-31 | $17,694 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2023-08-31 | $1,152 |
| 2022 : MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2022 401k financial data |
|---|
| Total plan liabilities at end of year | 2022-08-31 | $24,429 |
| Total plan liabilities at beginning of year | 2022-08-31 | $50,791 |
| Total income from all sources | 2022-08-31 | $280,947 |
| Expenses. Total of all expenses incurred | 2022-08-31 | $240,680 |
| Benefits paid (including direct rollovers) | 2022-08-31 | $131,182 |
| Total plan assets at end of year | 2022-08-31 | $83,046 |
| Total plan assets at beginning of year | 2022-08-31 | $69,141 |
| Value of fidelity bond covering the plan | 2022-08-31 | $206,000 |
| Total contributions received or receivable from participants | 2022-08-31 | $58,510 |
| Expenses. Other expenses not covered elsewhere | 2022-08-31 | $106,803 |
| Contributions received from other sources (not participants or employers) | 2022-08-31 | $0 |
| Other income received | 2022-08-31 | $750 |
| Noncash contributions received | 2022-08-31 | $0 |
| Net income (gross income less expenses) | 2022-08-31 | $40,267 |
| Net plan assets at end of year (total assets less liabilities) | 2022-08-31 | $58,617 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-08-31 | $18,350 |
| Total contributions received or receivable from employer(s) | 2022-08-31 | $221,687 |
| Value of corrective distributions | 2022-08-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2022-08-31 | $2,695 |
| 2021 : MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total plan liabilities at end of year | 2021-08-31 | $50,791 |
| Total plan liabilities at beginning of year | 2021-08-31 | $24,908 |
| Total income from all sources | 2021-08-31 | $278,576 |
| Expenses. Total of all expenses incurred | 2021-08-31 | $310,105 |
| Benefits paid (including direct rollovers) | 2021-08-31 | $191,041 |
| Total plan assets at end of year | 2021-08-31 | $69,141 |
| Total plan assets at beginning of year | 2021-08-31 | $74,787 |
| Value of fidelity bond covering the plan | 2021-08-31 | $206,000 |
| Total contributions received or receivable from participants | 2021-08-31 | $54,149 |
| Expenses. Other expenses not covered elsewhere | 2021-08-31 | $111,674 |
| Contributions received from other sources (not participants or employers) | 2021-08-31 | $8,281 |
| Other income received | 2021-08-31 | $440 |
| Net income (gross income less expenses) | 2021-08-31 | $-31,529 |
| Net plan assets at end of year (total assets less liabilities) | 2021-08-31 | $18,350 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-08-31 | $49,879 |
| Total contributions received or receivable from employer(s) | 2021-08-31 | $215,706 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2021-08-31 | $7,390 |
| 2020 : MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total plan liabilities at end of year | 2020-08-31 | $24,908 |
| Total plan liabilities at beginning of year | 2020-08-31 | $21,988 |
| Total income from all sources | 2020-08-31 | $348,187 |
| Expenses. Total of all expenses incurred | 2020-08-31 | $277,724 |
| Benefits paid (including direct rollovers) | 2020-08-31 | $120,500 |
| Total plan assets at end of year | 2020-08-31 | $74,787 |
| Total plan assets at beginning of year | 2020-08-31 | $1,404 |
| Value of fidelity bond covering the plan | 2020-08-31 | $206,000 |
| Total contributions received or receivable from participants | 2020-08-31 | $54,907 |
| Expenses. Other expenses not covered elsewhere | 2020-08-31 | $146,760 |
| Contributions received from other sources (not participants or employers) | 2020-08-31 | $7,603 |
| Other income received | 2020-08-31 | $338 |
| Net income (gross income less expenses) | 2020-08-31 | $70,463 |
| Net plan assets at end of year (total assets less liabilities) | 2020-08-31 | $49,879 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-08-31 | $-20,584 |
| Total contributions received or receivable from employer(s) | 2020-08-31 | $285,339 |
| Value of corrective distributions | 2020-08-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-08-31 | $10,464 |
| 2019 : MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total plan liabilities at end of year | 2019-08-31 | $21,988 |
| Total income from all sources | 2019-08-31 | $376,249 |
| Expenses. Total of all expenses incurred | 2019-08-31 | $396,833 |
| Benefits paid (including direct rollovers) | 2019-08-31 | $222,931 |
| Total plan assets at end of year | 2019-08-31 | $1,404 |
| Value of fidelity bond covering the plan | 2019-08-31 | $206,000 |
| Total contributions received or receivable from participants | 2019-08-31 | $59,063 |
| Expenses. Other expenses not covered elsewhere | 2019-08-31 | $160,910 |
| Contributions received from other sources (not participants or employers) | 2019-08-31 | $2,951 |
| Other income received | 2019-08-31 | $402 |
| Net income (gross income less expenses) | 2019-08-31 | $-20,584 |
| Net plan assets at end of year (total assets less liabilities) | 2019-08-31 | $-20,584 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-08-31 | $0 |
| Total contributions received or receivable from employer(s) | 2019-08-31 | $313,833 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-08-31 | $12,992 |
| 2022: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | Submission has been amended | No |
| 2022-09-01 | This submission is the final filing | No |
| 2022-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-09-01 | Plan is a collectively bargained plan | No |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan funding arrangement – Trust | Yes |
| 2022-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement - Trust | Yes |
| 2022-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Submission has been amended | No |
| 2021-09-01 | This submission is the final filing | No |
| 2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-09-01 | Plan is a collectively bargained plan | No |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan funding arrangement – Trust | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement - Trust | Yes |
| 2020: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Submission has been amended | No |
| 2020-09-01 | This submission is the final filing | No |
| 2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-09-01 | Plan is a collectively bargained plan | No |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – Trust | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement - Trust | Yes |
| 2019: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | No |
| 2019-09-01 | This submission is the final filing | No |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-09-01 | Plan is a collectively bargained plan | No |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement - Trust | Yes |
| 2018: MASON DIXON FARMS, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | First time form 5500 has been submitted | Yes |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement - Trust | Yes |
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 408380-A |
| Policy instance | 4 |
| Insurance contract or identification number | 408380-A | | Number of Individuals Covered | 17 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $66,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 8382107654 |
| Policy instance | 3 |
| Insurance contract or identification number | 8382107654 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 858833000 |
| Policy instance | 2 |
| Insurance contract or identification number | 858833000 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $1,123 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $8,108 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,123 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30700015 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700015 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2022-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $28,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 8382107654 |
| Policy instance | 3 |
| Insurance contract or identification number | 8382107654 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $69 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 858833000 |
| Policy instance | 2 |
| Insurance contract or identification number | 858833000 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $989 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $7,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $989 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30700015 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700015 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $95,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 8382107654 |
| Policy instance | 3 |
| Insurance contract or identification number | 8382107654 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $46 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 858833000 |
| Policy instance | 2 |
| Insurance contract or identification number | 858833000 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $837 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $7,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $837 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30700015 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700015 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $109,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | 8382107654 |
| Policy instance | 3 |
| Insurance contract or identification number | 8382107654 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $55 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
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| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 858833000 |
| Policy instance | 2 |
| Insurance contract or identification number | 858833000 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $839 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $6,623 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $839 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
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| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30700015 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700015 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $118,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NVA VISION (National Association of Insurance Commissioners NAIC id number: 11686 ) |
| Policy contract number | NVAI8382 |
| Policy instance | 3 |
| Insurance contract or identification number | NVAI8382 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $78 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
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| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 858833000 |
| Policy instance | 2 |
| Insurance contract or identification number | 858833000 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $903 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $7,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $903 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
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| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | PCI |
| Policy instance | 1 |
| Insurance contract or identification number | PCI | | Number of Individuals Covered | 29 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $141,324 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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