KOVATCH INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KOVATCH INC EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: KOVATCH INC EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 24 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 26 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 26 |
| 2021: KOVATCH INC EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 26 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 24 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 24 |
| 2020: KOVATCH INC EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 31 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 26 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 26 |
| 2019: KOVATCH INC EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 30 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 31 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 31 |
| 2018: KOVATCH INC EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 30 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 30 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 30 |
| Measure | Date | Value |
|---|
| 2023 : KOVATCH INC EMPLOYEE BENEFIT PLAN 2023 401k financial data |
|---|
| Total plan liabilities at end of year | 2023-06-30 | $16,732 |
| Total plan liabilities at beginning of year | 2023-06-30 | $18,029 |
| Total income from all sources | 2023-06-30 | $276,860 |
| Expenses. Total of all expenses incurred | 2023-06-30 | $341,460 |
| Benefits paid (including direct rollovers) | 2023-06-30 | $182,403 |
| Total plan assets at end of year | 2023-06-30 | $49,676 |
| Total plan assets at beginning of year | 2023-06-30 | $115,573 |
| Value of fidelity bond covering the plan | 2023-06-30 | $20,000 |
| Total contributions received or receivable from participants | 2023-06-30 | $0 |
| Expenses. Other expenses not covered elsewhere | 2023-06-30 | $100,566 |
| Contributions received from other sources (not participants or employers) | 2023-06-30 | $0 |
| Other income received | 2023-06-30 | $491 |
| Net income (gross income less expenses) | 2023-06-30 | $-64,600 |
| Net plan assets at end of year (total assets less liabilities) | 2023-06-30 | $32,944 |
| Net plan assets at beginning of year (total assets less liabilities) | 2023-06-30 | $97,544 |
| Total contributions received or receivable from employer(s) | 2023-06-30 | $276,369 |
| Value of corrective distributions | 2023-06-30 | $58,134 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2023-06-30 | $357 |
| 2022 : KOVATCH INC EMPLOYEE BENEFIT PLAN 2022 401k financial data |
|---|
| Total plan liabilities at end of year | 2022-06-30 | $18,029 |
| Total plan liabilities at beginning of year | 2022-06-30 | $17,683 |
| Total income from all sources | 2022-06-30 | $321,333 |
| Expenses. Total of all expenses incurred | 2022-06-30 | $294,801 |
| Benefits paid (including direct rollovers) | 2022-06-30 | $140,776 |
| Total plan assets at end of year | 2022-06-30 | $115,573 |
| Total plan assets at beginning of year | 2022-06-30 | $88,695 |
| Value of fidelity bond covering the plan | 2022-06-30 | $20,000 |
| Total contributions received or receivable from participants | 2022-06-30 | $38,130 |
| Expenses. Other expenses not covered elsewhere | 2022-06-30 | $115,340 |
| Contributions received from other sources (not participants or employers) | 2022-06-30 | $0 |
| Other income received | 2022-06-30 | $295 |
| Net income (gross income less expenses) | 2022-06-30 | $26,532 |
| Net plan assets at end of year (total assets less liabilities) | 2022-06-30 | $97,544 |
| Net plan assets at beginning of year (total assets less liabilities) | 2022-06-30 | $71,012 |
| Total contributions received or receivable from employer(s) | 2022-06-30 | $282,908 |
| Value of corrective distributions | 2022-06-30 | $36,554 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2022-06-30 | $2,131 |
| 2021 : KOVATCH INC EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total plan liabilities at end of year | 2021-06-30 | $17,683 |
| Total plan liabilities at beginning of year | 2021-06-30 | $38,385 |
| Total income from all sources | 2021-06-30 | $339,695 |
| Expenses. Total of all expenses incurred | 2021-06-30 | $402,411 |
| Benefits paid (including direct rollovers) | 2021-06-30 | $277,540 |
| Total plan assets at end of year | 2021-06-30 | $88,695 |
| Total plan assets at beginning of year | 2021-06-30 | $172,113 |
| Value of fidelity bond covering the plan | 2021-06-30 | $20,000 |
| Total contributions received or receivable from participants | 2021-06-30 | $103,753 |
| Expenses. Other expenses not covered elsewhere | 2021-06-30 | $113,491 |
| Contributions received from other sources (not participants or employers) | 2021-06-30 | $0 |
| Other income received | 2021-06-30 | $334 |
| Net income (gross income less expenses) | 2021-06-30 | $-62,716 |
| Net plan assets at end of year (total assets less liabilities) | 2021-06-30 | $71,012 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-06-30 | $133,728 |
| Total contributions received or receivable from employer(s) | 2021-06-30 | $235,608 |
| Value of corrective distributions | 2021-06-30 | $4,566 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2021-06-30 | $6,814 |
| 2020 : KOVATCH INC EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total plan liabilities at end of year | 2020-06-30 | $38,385 |
| Total plan liabilities at beginning of year | 2020-06-30 | $30,462 |
| Total income from all sources | 2020-06-30 | $363,831 |
| Expenses. Total of all expenses incurred | 2020-06-30 | $218,122 |
| Benefits paid (including direct rollovers) | 2020-06-30 | $83,971 |
| Total plan assets at end of year | 2020-06-30 | $172,113 |
| Total plan assets at beginning of year | 2020-06-30 | $18,481 |
| Value of fidelity bond covering the plan | 2020-06-30 | $20,000 |
| Total contributions received or receivable from participants | 2020-06-30 | $90,262 |
| Expenses. Other expenses not covered elsewhere | 2020-06-30 | $119,155 |
| Contributions received from other sources (not participants or employers) | 2020-06-30 | $0 |
| Other income received | 2020-06-30 | $97 |
| Net income (gross income less expenses) | 2020-06-30 | $145,709 |
| Net plan assets at end of year (total assets less liabilities) | 2020-06-30 | $133,728 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-06-30 | $-11,981 |
| Total contributions received or receivable from employer(s) | 2020-06-30 | $273,472 |
| Value of corrective distributions | 2020-06-30 | $3,664 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-06-30 | $11,332 |
| 2019 : KOVATCH INC EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total plan liabilities at end of year | 2019-06-30 | $30,462 |
| Total income from all sources | 2019-06-30 | $315,283 |
| Expenses. Total of all expenses incurred | 2019-06-30 | $327,264 |
| Benefits paid (including direct rollovers) | 2019-06-30 | $210,379 |
| Total plan assets at end of year | 2019-06-30 | $18,481 |
| Value of fidelity bond covering the plan | 2019-06-30 | $20,000 |
| Total contributions received or receivable from participants | 2019-06-30 | $105,140 |
| Expenses. Other expenses not covered elsewhere | 2019-06-30 | $105,216 |
| Other income received | 2019-06-30 | $63 |
| Net income (gross income less expenses) | 2019-06-30 | $-11,981 |
| Net plan assets at end of year (total assets less liabilities) | 2019-06-30 | $-11,981 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-06-30 | $0 |
| Total contributions received or receivable from employer(s) | 2019-06-30 | $210,080 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-06-30 | $11,669 |
| 2022: KOVATCH INC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – Trust | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement - Trust | Yes |
| 2022-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: KOVATCH INC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Submission has been amended | No |
| 2021-07-01 | This submission is the final filing | No |
| 2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-07-01 | Plan is a collectively bargained plan | No |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – Trust | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement - Trust | Yes |
| 2020: KOVATCH INC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – Trust | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement - Trust | Yes |
| 2019: KOVATCH INC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – Trust | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement - Trust | Yes |
| 2018: KOVATCH INC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | First time form 5500 has been submitted | Yes |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – Trust | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement - Trust | Yes |
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0000043990 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000043990 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 932776 |
| Policy instance | 3 |
| Insurance contract or identification number | 932776 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $4,249 | | 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 | ACCIDENT, VOLUNTARY EMPLOYEE, SPOUSE AND CHILD LIFE/AD&D, CRITICAL ILLNESS | | 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 $21,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,249 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | 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 | 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 $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 | 31000016 |
| Policy instance | 1 |
| Insurance contract or identification number | 31000016 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | 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 $85,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 31000016 |
| Policy instance | 1 |
| Insurance contract or identification number | 31000016 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | 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 $97,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | 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 | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 932776 |
| Policy instance | 3 |
| Insurance contract or identification number | 932776 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $5,536 | | 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 | ACCIDENT, VOLUNTARY EMPLOYEE, SPOUSE AND CHILD LIFE/AD&D, CRITICAL ILLNESS | | 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 $26,978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,536 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0000043990 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000043990 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $191 | | 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 $3,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $191 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0000043990 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000043990 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $214 | | 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 $3,534 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $109 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 932776 |
| Policy instance | 3 |
| Insurance contract or identification number | 932776 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $5,465 | | 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 | ACCIDENT, VOLUNTARY EMPLOYEE, SPOUSE AND CHILD LIFE/AD&D, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,465 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | 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 | 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 | | 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 | 31000016 |
| Policy instance | 1 |
| Insurance contract or identification number | 31000016 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | 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 $93,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | 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 | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 932776 |
| Policy instance | 3 |
| Insurance contract or identification number | 932776 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $6,226 | | 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 | ACCIDENT, VOLUNTARY EMPLOYEE, SPOUSE AND CHILD LIFE/AD&D, CRITICAL ILLNESS | | 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 $31,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,226 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0000043990 |
| Policy instance | 4 |
| Insurance contract or identification number | 0000043990 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $244 | | 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 $4,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $244 | | 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 | 31000016 |
| Policy instance | 1 |
| Insurance contract or identification number | 31000016 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | 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 $96,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | 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 | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | ACCIDENT AND CR |
| Policy instance | 3 |
| Insurance contract or identification number | ACCIDENT AND CR | | Number of Individuals Covered | 17 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $435 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT AND CRITICAL ILLNESS | | 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 $4,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $435 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F022693 |
| Policy instance | 4 |
| Insurance contract or identification number | F022693 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,636 | | Total amount of fees paid to insurance company | USD $1,212 | | 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 VOL | | 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 $24,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,636 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0000043990 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000043990 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $240 | | 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 $4,347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $240 | | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 30 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | 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 $82,407 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
