LESHER MACK SALES & SERVICE, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 33 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 33 |
| 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 | 33 |
| 2021: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 37 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 33 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 33 |
| 2020: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 39 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 37 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 37 |
| 2019: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 35 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 39 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 39 |
| 2018: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 27 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 35 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 35 |
| 2017: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 28 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 27 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 27 |
| Measure | Date | Value |
|---|
| 2022 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2022 401k financial data |
|---|
| Total plan liabilities at end of year | 2022-12-31 | $125,179 |
| Total plan liabilities at beginning of year | 2022-12-31 | $25,991 |
| Total income from all sources | 2022-12-31 | $373,875 |
| Expenses. Total of all expenses incurred | 2022-12-31 | $481,029 |
| Benefits paid (including direct rollovers) | 2022-12-31 | $316,101 |
| Total plan assets at end of year | 2022-12-31 | $15,552 |
| Total plan assets at beginning of year | 2022-12-31 | $23,518 |
| Value of fidelity bond covering the plan | 2022-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2022-12-31 | $98,080 |
| Expenses. Other expenses not covered elsewhere | 2022-12-31 | $150,891 |
| Contributions received from other sources (not participants or employers) | 2022-12-31 | $1,736 |
| Other income received | 2022-12-31 | $72 |
| Net income (gross income less expenses) | 2022-12-31 | $-107,154 |
| Net plan assets at end of year (total assets less liabilities) | 2022-12-31 | $-109,627 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-12-31 | $-2,473 |
| Total contributions received or receivable from employer(s) | 2022-12-31 | $273,987 |
| Value of corrective distributions | 2022-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2022-12-31 | $14,037 |
| 2021 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total plan liabilities at end of year | 2021-12-31 | $25,991 |
| Total plan liabilities at beginning of year | 2021-12-31 | $48,156 |
| Total income from all sources | 2021-12-31 | $326,367 |
| Expenses. Total of all expenses incurred | 2021-12-31 | $283,726 |
| Benefits paid (including direct rollovers) | 2021-12-31 | $148,121 |
| Total plan assets at end of year | 2021-12-31 | $23,518 |
| Total plan assets at beginning of year | 2021-12-31 | $3,042 |
| Value of fidelity bond covering the plan | 2021-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2021-12-31 | $86,990 |
| Expenses. Other expenses not covered elsewhere | 2021-12-31 | $141,902 |
| Other income received | 2021-12-31 | $55 |
| Net income (gross income less expenses) | 2021-12-31 | $42,641 |
| Net plan assets at end of year (total assets less liabilities) | 2021-12-31 | $-2,473 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-12-31 | $-45,114 |
| Total contributions received or receivable from employer(s) | 2021-12-31 | $239,322 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2021-12-31 | $-6,297 |
| 2020 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total plan liabilities at end of year | 2020-12-31 | $48,156 |
| Total plan liabilities at beginning of year | 2020-12-31 | $32,134 |
| Total income from all sources | 2020-12-31 | $344,222 |
| Expenses. Total of all expenses incurred | 2020-12-31 | $359,705 |
| Benefits paid (including direct rollovers) | 2020-12-31 | $211,955 |
| Total plan assets at end of year | 2020-12-31 | $3,042 |
| Total plan assets at beginning of year | 2020-12-31 | $2,503 |
| Value of fidelity bond covering the plan | 2020-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2020-12-31 | $88,708 |
| Expenses. Other expenses not covered elsewhere | 2020-12-31 | $132,686 |
| Contributions received from other sources (not participants or employers) | 2020-12-31 | $4,842 |
| Other income received | 2020-12-31 | $37 |
| Net income (gross income less expenses) | 2020-12-31 | $-15,483 |
| Net plan assets at end of year (total assets less liabilities) | 2020-12-31 | $-45,114 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-12-31 | $-29,631 |
| Total contributions received or receivable from employer(s) | 2020-12-31 | $250,635 |
| Value of corrective distributions | 2020-12-31 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-12-31 | $15,064 |
| 2019 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total plan liabilities at end of year | 2019-12-31 | $32,134 |
| Total plan liabilities at beginning of year | 2019-12-31 | $30,168 |
| Total income from all sources | 2019-12-31 | $335,430 |
| Expenses. Total of all expenses incurred | 2019-12-31 | $371,743 |
| Benefits paid (including direct rollovers) | 2019-12-31 | $220,510 |
| Total plan assets at end of year | 2019-12-31 | $2,503 |
| Total plan assets at beginning of year | 2019-12-31 | $36,850 |
| Value of fidelity bond covering the plan | 2019-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2019-12-31 | $80,597 |
| Expenses. Other expenses not covered elsewhere | 2019-12-31 | $125,478 |
| Contributions received from other sources (not participants or employers) | 2019-12-31 | $1,634 |
| Other income received | 2019-12-31 | $73 |
| Net income (gross income less expenses) | 2019-12-31 | $-36,313 |
| Net plan assets at end of year (total assets less liabilities) | 2019-12-31 | $-29,631 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-12-31 | $6,682 |
| Total contributions received or receivable from employer(s) | 2019-12-31 | $253,126 |
| Value of corrective distributions | 2019-12-31 | $8,626 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-12-31 | $17,129 |
| 2018 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2018 401k financial data |
|---|
| Total plan liabilities at end of year | 2018-12-31 | $30,168 |
| Total plan liabilities at beginning of year | 2018-12-31 | $410 |
| Total income from all sources | 2018-12-31 | $267,642 |
| Expenses. Total of all expenses incurred | 2018-12-31 | $281,663 |
| Benefits paid (including direct rollovers) | 2018-12-31 | $152,494 |
| Total plan assets at end of year | 2018-12-31 | $36,850 |
| Total plan assets at beginning of year | 2018-12-31 | $21,113 |
| Value of fidelity bond covering the plan | 2018-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2018-12-31 | $66,050 |
| Expenses. Other expenses not covered elsewhere | 2018-12-31 | $102,189 |
| Other income received | 2018-12-31 | $76 |
| Net income (gross income less expenses) | 2018-12-31 | $-14,021 |
| Net plan assets at end of year (total assets less liabilities) | 2018-12-31 | $6,682 |
| Net plan assets at beginning of year (total assets less liabilities) | 2018-12-31 | $20,703 |
| Total contributions received or receivable from employer(s) | 2018-12-31 | $201,516 |
| Value of corrective distributions | 2018-12-31 | $12,077 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2018-12-31 | $14,903 |
| 2017 : LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2017 401k financial data |
|---|
| Total plan liabilities at end of year | 2017-12-31 | $410 |
| Total plan liabilities at beginning of year | 2017-12-31 | $0 |
| Total income from all sources | 2017-12-31 | $119,457 |
| Expenses. Total of all expenses incurred | 2017-12-31 | $98,754 |
| Benefits paid (including direct rollovers) | 2017-12-31 | $44,314 |
| Total plan assets at end of year | 2017-12-31 | $21,113 |
| Total plan assets at beginning of year | 2017-12-31 | $0 |
| Value of fidelity bond covering the plan | 2017-12-31 | $1,000,000 |
| Total contributions received or receivable from participants | 2017-12-31 | $33,757 |
| Expenses. Other expenses not covered elsewhere | 2017-12-31 | $46,967 |
| Other income received | 2017-12-31 | $9 |
| Net income (gross income less expenses) | 2017-12-31 | $20,703 |
| Net plan assets at end of year (total assets less liabilities) | 2017-12-31 | $20,703 |
| Net plan assets at beginning of year (total assets less liabilities) | 2017-12-31 | $0 |
| Total contributions received or receivable from employer(s) | 2017-12-31 | $85,691 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2017-12-31 | $7,473 |
| 2022: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 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 funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement - Trust | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – Trust | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement - Trust | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – Trust | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement - Trust | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – Trust | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement - Trust | Yes |
| 2018: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – Trust | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement - Trust | Yes |
| 2017: LESHER MACK SALES & SERVICE, INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | First time form 5500 has been submitted | Yes |
| 2017-06-01 | Submission has been amended | No |
| 2017-06-01 | This submission is the final filing | No |
| 2017-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-06-01 | Plan is a collectively bargained plan | No |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – Trust | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement - Trust | Yes |
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0000 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,006 | | 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 $9,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,006 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $456 | | 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 $2,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $456 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000 | | Number of Individuals Covered | 0 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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? | Yes |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500277 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500277 | | Number of Individuals Covered | 33 | | 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 $131,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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? | Yes |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500277 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500277 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2021-01-01 | | 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 $120,492 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 877633G |
| Policy instance | 2 |
| Insurance contract or identification number | 877633G | | Number of Individuals Covered | 37 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,017 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $20,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,689 | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500277 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500277 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 $113,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 877633GRH,GLT,G |
| Policy instance | 2 |
| Insurance contract or identification number | 877633GRH,GLT,G | | Number of Individuals Covered | 39 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,972 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $19,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,972 | | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 36 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 $104,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 877633GRH,GLT,G |
| Policy instance | 2 |
| Insurance contract or identification number | 877633GRH,GLT,G | | Number of Individuals Covered | 35 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,847 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $18,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,847 | | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 32 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2018-12-31 | | 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 $83,484 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | GRH-877633 |
| Policy instance | 2 |
| Insurance contract or identification number | GRH-877633 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,665 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $16,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,665 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD E FAILOR ASSOC LLC |
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| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 27 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2017-12-31 | | 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 $37,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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