COUNTRY CUPBOARD, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COUNTRY CUPBOARD, INC. - CAFETERIA PLAN
401k plan membership statisitcs for COUNTRY CUPBOARD, INC. - CAFETERIA PLAN
Measure | Date | Value |
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2022: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 67 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 28 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 28 |
2021: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-10-01 | 82 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 67 |
Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
Total of all active and inactive participants | 2021-10-01 | 67 |
2020: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-10-01 | 97 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 82 |
Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
Total of all active and inactive participants | 2020-10-01 | 82 |
2019: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-10-01 | 97 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 97 |
Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
Total of all active and inactive participants | 2019-10-01 | 97 |
2018: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-10-01 | 96 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 96 |
Number of retired or separated participants receiving benefits | 2018-10-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
Total of all active and inactive participants | 2018-10-01 | 97 |
2017: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-10-01 | 106 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 92 |
Number of retired or separated participants receiving benefits | 2017-10-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
Total of all active and inactive participants | 2017-10-01 | 96 |
2013: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 136 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 91 |
Total of all active and inactive participants | 2013-01-01 | 91 |
2012: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-01-01 | 137 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 136 |
Total of all active and inactive participants | 2012-01-01 | 136 |
2011: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 163 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 137 |
Total of all active and inactive participants | 2011-01-01 | 137 |
2009: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-01-01 | 109 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 110 |
Total of all active and inactive participants | 2009-01-01 | 110 |
Measure | Date | Value |
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2022 : COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2022 401k financial data |
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Total plan liabilities at end of year | 2022-12-31 | $20,839 |
Total plan liabilities at beginning of year | 2022-12-31 | $64,576 |
Total income from all sources | 2022-12-31 | $310,834 |
Expenses. Total of all expenses incurred | 2022-12-31 | $240,767 |
Benefits paid (including direct rollovers) | 2022-12-31 | $119,376 |
Total plan assets at end of year | 2022-12-31 | $28,527 |
Total plan assets at beginning of year | 2022-12-31 | $2,197 |
Value of fidelity bond covering the plan | 2022-12-31 | $500,000 |
Total contributions received or receivable from participants | 2022-12-31 | $93,491 |
Expenses. Other expenses not covered elsewhere | 2022-12-31 | $109,977 |
Other income received | 2022-12-31 | $53 |
Net income (gross income less expenses) | 2022-12-31 | $70,067 |
Net plan assets at end of year (total assets less liabilities) | 2022-12-31 | $7,688 |
Net plan assets at beginning of year (total assets less liabilities) | 2022-12-31 | $-62,379 |
Total contributions received or receivable from employer(s) | 2022-12-31 | $217,290 |
Expenses. Administrative service providers (salaries,fees and commissions) | 2022-12-31 | $11,414 |
2021 : COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2021 401k financial data |
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Total plan liabilities at end of year | 2021-12-31 | $64,576 |
Total plan liabilities at beginning of year | 2021-12-31 | $51,942 |
Total income from all sources | 2021-12-31 | $114,437 |
Expenses. Total of all expenses incurred | 2021-12-31 | $128,540 |
Benefits paid (including direct rollovers) | 2021-12-31 | $79,950 |
Total plan assets at end of year | 2021-12-31 | $2,197 |
Total plan assets at beginning of year | 2021-12-31 | $3,666 |
Value of fidelity bond covering the plan | 2021-12-31 | $500,000 |
Total contributions received or receivable from participants | 2021-12-31 | $46,908 |
Expenses. Other expenses not covered elsewhere | 2021-12-31 | $42,662 |
Other income received | 2021-12-31 | $15 |
Net income (gross income less expenses) | 2021-12-31 | $-14,103 |
Net plan assets at end of year (total assets less liabilities) | 2021-12-31 | $-62,379 |
Net plan assets at beginning of year (total assets less liabilities) | 2021-12-31 | $-48,276 |
Total contributions received or receivable from employer(s) | 2021-12-31 | $67,514 |
Expenses. Administrative service providers (salaries,fees and commissions) | 2021-12-31 | $5,928 |
Total plan liabilities at end of year | 2021-09-30 | $51,942 |
Total plan liabilities at beginning of year | 2021-09-30 | $0 |
Total income from all sources | 2021-09-30 | $527,392 |
Expenses. Total of all expenses incurred | 2021-09-30 | $575,668 |
Benefits paid (including direct rollovers) | 2021-09-30 | $352,306 |
Total plan assets at end of year | 2021-09-30 | $3,666 |
Total plan assets at beginning of year | 2021-09-30 | $0 |
Value of fidelity bond covering the plan | 2021-09-30 | $500,000 |
Total contributions received or receivable from participants | 2021-09-30 | $200,295 |
Expenses. Other expenses not covered elsewhere | 2021-09-30 | $196,776 |
Other income received | 2021-09-30 | $49 |
Net income (gross income less expenses) | 2021-09-30 | $-48,276 |
Net plan assets at end of year (total assets less liabilities) | 2021-09-30 | $-48,276 |
Net plan assets at beginning of year (total assets less liabilities) | 2021-09-30 | $0 |
Total contributions received or receivable from employer(s) | 2021-09-30 | $327,048 |
Expenses. Administrative service providers (salaries,fees and commissions) | 2021-09-30 | $26,586 |
2022: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Submission has been amended | No |
2022-01-01 | This submission is the final filing | No |
2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-01-01 | Plan is a collectively bargained plan | No |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – Trust | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement - Trust | Yes |
2021: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2021 form 5500 responses |
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2021-10-01 | Type of plan entity | Single employer plan |
2021-10-01 | Submission has been amended | No |
2021-10-01 | This submission is the final filing | No |
2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2021-10-01 | Plan is a collectively bargained plan | No |
2021-10-01 | Plan funding arrangement – Insurance | Yes |
2021-10-01 | Plan funding arrangement – Trust | Yes |
2021-10-01 | Plan benefit arrangement – Insurance | Yes |
2021-10-01 | Plan benefit arrangement - Trust | Yes |
2020: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2020 form 5500 responses |
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2020-10-01 | Type of plan entity | Single employer plan |
2020-10-01 | Submission has been amended | No |
2020-10-01 | This submission is the final filing | No |
2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-10-01 | Plan is a collectively bargained plan | No |
2020-10-01 | Plan funding arrangement – Insurance | Yes |
2020-10-01 | Plan funding arrangement – Trust | Yes |
2020-10-01 | Plan benefit arrangement – Insurance | Yes |
2020-10-01 | Plan benefit arrangement - Trust | Yes |
2019: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2019 form 5500 responses |
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2019-10-01 | Type of plan entity | Single employer plan |
2019-10-01 | Submission has been amended | No |
2019-10-01 | This submission is the final filing | No |
2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-10-01 | Plan is a collectively bargained plan | No |
2019-10-01 | Plan funding arrangement – Insurance | Yes |
2019-10-01 | Plan benefit arrangement – Insurance | Yes |
2018: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2018 form 5500 responses |
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2018-10-01 | Type of plan entity | Single employer plan |
2018-10-01 | Submission has been amended | No |
2018-10-01 | This submission is the final filing | No |
2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-10-01 | Plan is a collectively bargained plan | No |
2018-10-01 | Plan funding arrangement – Insurance | Yes |
2018-10-01 | Plan benefit arrangement – Insurance | Yes |
2017: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2017 form 5500 responses |
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2017-10-01 | Type of plan entity | Single employer plan |
2017-10-01 | Submission has been amended | No |
2017-10-01 | This submission is the final filing | No |
2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-10-01 | Plan is a collectively bargained plan | No |
2017-10-01 | Plan funding arrangement – Insurance | Yes |
2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-10-01 | Plan benefit arrangement – Insurance | Yes |
2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Mulitple employer plan |
2013-01-01 | Plan funding arrangement – Insurance | Yes |
2013-01-01 | Plan benefit arrangement – Insurance | Yes |
2012: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2012 form 5500 responses |
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2012-01-01 | Type of plan entity | Mulitple employer plan |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2011: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Mulitple employer plan |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2009: COUNTRY CUPBOARD, INC. - CAFETERIA PLAN 2009 form 5500 responses |
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2009-01-01 | Type of plan entity | Mulitple employer plan |
2009-01-01 | Submission has been amended | Yes |
2009-01-01 | This submission is the final filing | No |
2009-01-01 | Plan funding arrangement – Insurance | Yes |
2009-01-01 | Plan benefit arrangement – Insurance | Yes |
DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 3 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 36 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $889 | 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 $17,777 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $889 | 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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VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 2 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 31 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $166 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $166 | 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 | 30500622 |
Policy instance | 1 |
Insurance contract or identification number | 30500622 | Number of Individuals Covered | 28 | Insurance policy start date | 2022-01-01 | 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 $85,496 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 3 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 63 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $334 | 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 $6,687 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $223 | 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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VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 2 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 59 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $60 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $60 | 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 | 30500622 |
Policy instance | 1 |
Insurance contract or identification number | 30500622 | Number of Individuals Covered | 67 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | 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 $31,318 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 3 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 68 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,489 | 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 $29,776 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,489 | 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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VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 2 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 60 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $257 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $257 | 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 | 30500622 |
Policy instance | 1 |
Insurance contract or identification number | 30500622 | Number of Individuals Covered | 82 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 3 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 79 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $1,786 | 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 $33,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,786 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | NONE | Insurance broker organization code? | 3 |
|
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 2 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 71 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $335 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $335 | 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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GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 ) |
Policy contract number | 10118245 |
Policy instance | 1 |
Insurance contract or identification number | 10118245 | Number of Individuals Covered | 111 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $37,405 | 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 | Yes | 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 $623,411 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,405 | 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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DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 3 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 77 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,501 | 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 $30,016 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,501 | 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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VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 2 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 80 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $368 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $368 | 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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CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
Policy contract number | 00700268 |
Policy instance | 1 |
Insurance contract or identification number | 00700268 | Number of Individuals Covered | 96 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $39,138 | 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 | Yes | 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 $573,293 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $39,138 | 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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DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
Policy contract number | 17433 |
Policy instance | 4 |
Insurance contract or identification number | 17433 | Number of Individuals Covered | 54 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,156 | 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 $23,113 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
Policy contract number | 3664 |
Policy instance | 3 |
Insurance contract or identification number | 3664 | Number of Individuals Covered | 77 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $340 | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
Policy contract number | 947-5556 |
Policy instance | 2 |
Insurance contract or identification number | 947-5556 | Number of Individuals Covered | 92 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,502 | Total amount of fees paid to insurance company | USD $525 | 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 | Other welfare benefits provided | TRANSPLANT | 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 $15,021 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
Policy contract number | GER-HA-090 |
Policy instance | 1 |
Insurance contract or identification number | GER-HA-090 | Number of Individuals Covered | 92 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | 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 $182,864 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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