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STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 401k Plan overview

Plan NameSTEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN
Plan identification number 501

STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

STEVE SHANNON TIRE COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name:STEVE SHANNON TIRE COMPANY, INC.
Employer identification number (EIN):232549609
NAIC Classification:423100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01KELLY SHANNON
5012016-01-01KELLY SHANNON
5012016-01-01KELLY SHANNON
5012015-01-01KELLY SHANNON KELLY SHANNON2016-07-20
5012014-01-01KELLY SHANNON KELLY SHANNON2015-06-24
5012013-01-01KELLY SHANNON KELLY SHANNON2014-06-16
5012012-01-01KELLY SHANNON KELLY SHANNON2013-07-29
5012011-01-01KELLY SHANNON
5012010-01-01KELLY SHANNON
5012009-01-01KELLY SHANNON

Plan Statistics for STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN

401k plan membership statisitcs for STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN

Measure Date Value
2022: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01142
Total number of active participants reported on line 7a of the Form 55002022-01-01179
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01179
2021: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01142
Total number of active participants reported on line 7a of the Form 55002021-01-01142
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01142
2020: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01108
Total number of active participants reported on line 7a of the Form 55002020-01-01142
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01142
2019: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01125
Total number of active participants reported on line 7a of the Form 55002019-01-01108
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01108
2018: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01120
Total number of active participants reported on line 7a of the Form 55002018-01-01125
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01125
2017: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01119
Total number of active participants reported on line 7a of the Form 55002017-01-01120
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01120
2016: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01136
Total number of active participants reported on line 7a of the Form 55002016-01-01119
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01119
2015: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01192
Total number of active participants reported on line 7a of the Form 55002015-01-01136
Total of all active and inactive participants2015-01-01136
Total participants2015-01-01136
2014: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01131
Total number of active participants reported on line 7a of the Form 55002014-01-01192
Total of all active and inactive participants2014-01-01192
Total participants2014-01-01192
2013: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01133
Total number of active participants reported on line 7a of the Form 55002013-01-01131
Total of all active and inactive participants2013-01-01131
Total participants2013-01-01131
2012: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01134
Total number of active participants reported on line 7a of the Form 55002012-01-01133
Total of all active and inactive participants2012-01-01133
Total participants2012-01-01133
2011: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01107
Total number of active participants reported on line 7a of the Form 55002011-01-01134
Total of all active and inactive participants2011-01-01134
Total participants2011-01-01134
2010: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01139
Total number of active participants reported on line 7a of the Form 55002010-01-01107
Total of all active and inactive participants2010-01-01107
Total participants2010-01-01107
2009: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01150
Total number of active participants reported on line 7a of the Form 55002009-01-01139
Total of all active and inactive participants2009-01-01139
Total participants2009-01-01139

Financial Data on STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN

Measure Date Value
2022 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$116,320
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$105,009
Total income from all sources (including contributions)2022-12-31$1,860,825
Total loss/gain on sale of assets2022-12-31$0
Total of all expenses incurred2022-12-31$1,533,821
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$916,090
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$1,860,758
Value of total assets at end of year2022-12-31$593,231
Value of total assets at beginning of year2022-12-31$254,916
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$617,731
Total interest from all sources2022-12-31$67
Total dividends received (eg from common stock, registered investment company shares)2022-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$260,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$491,546
Value of other receiveables (less allowance for doubtful accounts) at end of year2022-12-31$322
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2022-12-31$4,058
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2022-12-31$88,506
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2022-12-31$87,935
Administrative expenses (other) incurred2022-12-31$450,493
Liabilities. Value of operating payables at end of year2022-12-31$217
Liabilities. Value of operating payables at beginning of year2022-12-31$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$327,004
Value of net assets at end of year (total assets less liabilities)2022-12-31$476,911
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$149,907
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Investment advisory and management fees2022-12-31$43,089
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2022-12-31$592,909
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2022-12-31$250,858
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2022-12-31$250,858
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2022-12-31$67
Expenses. Payments to insurance carriers foe the provision of benefits2022-12-31$916,090
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$1,369,212
Contract administrator fees2022-12-31$124,149
Liabilities. Value of benefit claims payable at end of year2022-12-31$27,597
Liabilities. Value of benefit claims payable at beginning of year2022-12-31$17,074
Did the plan have assets held for investment2022-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2022-12-31251589048
2021 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$105,009
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$111,345
Total income from all sources (including contributions)2021-12-31$1,427,734
Total loss/gain on sale of assets2021-12-31$0
Total of all expenses incurred2021-12-31$1,317,994
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$845,858
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$1,427,198
Value of total assets at end of year2021-12-31$254,916
Value of total assets at beginning of year2021-12-31$151,512
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$472,136
Total interest from all sources2021-12-31$536
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$260,000
If this is an individual account plan, was there a blackout period2021-12-31No
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$378,564
Value of other receiveables (less allowance for doubtful accounts) at end of year2021-12-31$4,058
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2021-12-31$4,145
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2021-12-31$87,935
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2021-12-31$105,707
Administrative expenses (other) incurred2021-12-31$325,527
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$109,740
Value of net assets at end of year (total assets less liabilities)2021-12-31$149,907
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$40,167
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Investment advisory and management fees2021-12-31$35,451
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2021-12-31$250,858
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2021-12-31$147,367
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2021-12-31$147,367
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2021-12-31$536
Expenses. Payments to insurance carriers foe the provision of benefits2021-12-31$845,858
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$1,048,634
Contract administrator fees2021-12-31$111,158
Liabilities. Value of benefit claims payable at end of year2021-12-31$17,074
Liabilities. Value of benefit claims payable at beginning of year2021-12-31$5,638
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2021-12-31251589048
2020 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$111,345
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$100,548
Total income from all sources (including contributions)2020-12-31$1,281,724
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$1,172,620
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$759,621
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,281,464
Value of total assets at end of year2020-12-31$151,512
Value of total assets at beginning of year2020-12-31$31,611
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$412,999
Total interest from all sources2020-12-31$260
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$260,000
If this is an individual account plan, was there a blackout period2020-12-31No
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Value of other receiveables (less allowance for doubtful accounts) at end of year2020-12-31$4,145
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2020-12-31$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2020-12-31$105,707
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2020-12-31$68,343
Administrative expenses (other) incurred2020-12-31$276,318
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$109,104
Value of net assets at end of year (total assets less liabilities)2020-12-31$40,167
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$-68,937
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Investment advisory and management fees2020-12-31$30,410
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2020-12-31$147,367
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2020-12-31$31,611
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2020-12-31$31,611
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2020-12-31$260
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$759,621
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$1,281,464
Contract administrator fees2020-12-31$106,271
Liabilities. Value of benefit claims payable at end of year2020-12-31$5,638
Liabilities. Value of benefit claims payable at beginning of year2020-12-31$32,205
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2020-12-31251589048
2019 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$100,548
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$100,548
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$18,668
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$18,668
Total income from all sources (including contributions)2019-12-31$1,180,320
Total income from all sources (including contributions)2019-12-31$1,180,320
Total loss/gain on sale of assets2019-12-31$0
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$1,312,585
Total of all expenses incurred2019-12-31$1,312,585
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$905,897
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$905,897
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$1,179,991
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$1,179,991
Value of total assets at end of year2019-12-31$31,611
Value of total assets at end of year2019-12-31$31,611
Value of total assets at beginning of year2019-12-31$81,996
Value of total assets at beginning of year2019-12-31$81,996
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$406,688
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$406,688
Total interest from all sources2019-12-31$329
Total interest from all sources2019-12-31$329
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31Yes
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$260,000
Value of fidelity bond cover2019-12-31$260,000
If this is an individual account plan, was there a blackout period2019-12-31No
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$330,603
Contributions received from participants2019-12-31$330,603
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2019-12-31$68,343
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2019-12-31$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2019-12-31$0
Administrative expenses (other) incurred2019-12-31$261,140
Administrative expenses (other) incurred2019-12-31$261,140
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$-132,265
Value of net income/loss2019-12-31$-132,265
Value of net assets at end of year (total assets less liabilities)2019-12-31$-68,937
Value of net assets at end of year (total assets less liabilities)2019-12-31$-68,937
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$63,328
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$63,328
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Investment advisory and management fees2019-12-31$31,105
Investment advisory and management fees2019-12-31$31,105
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2019-12-31$31,611
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2019-12-31$31,611
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2019-12-31$81,996
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2019-12-31$81,996
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2019-12-31$81,996
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2019-12-31$81,996
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2019-12-31$329
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2019-12-31$329
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$905,897
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$905,897
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$849,388
Contributions received in cash from employer2019-12-31$849,388
Contract administrator fees2019-12-31$114,443
Contract administrator fees2019-12-31$114,443
Liabilities. Value of benefit claims payable at end of year2019-12-31$32,205
Liabilities. Value of benefit claims payable at end of year2019-12-31$32,205
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$18,668
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$18,668
Did the plan have assets held for investment2019-12-31Yes
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm name2019-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2019-12-31251589048
Accountancy firm EIN2019-12-31251589048
2018 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets2018-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$18,668
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$7,086
Total income from all sources (including contributions)2018-12-31$1,022,207
Total loss/gain on sale of assets2018-12-31$0
Total of all expenses incurred2018-12-31$1,097,667
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$744,462
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$1,021,855
Value of total assets at end of year2018-12-31$81,996
Value of total assets at beginning of year2018-12-31$145,874
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$353,205
Total interest from all sources2018-12-31$352
Total dividends received (eg from common stock, registered investment company shares)2018-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$260,000
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Contributions received from participants2018-12-31$324,383
Administrative expenses (other) incurred2018-12-31$218,141
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$-75,460
Value of net assets at end of year (total assets less liabilities)2018-12-31$63,328
Value of net assets at beginning of year (total assets less liabilities)2018-12-31$138,788
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Investment advisory and management fees2018-12-31$29,402
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2018-12-31$81,996
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2018-12-31$145,874
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2018-12-31$145,874
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2018-12-31$352
Expenses. Payments to insurance carriers foe the provision of benefits2018-12-31$744,462
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contributions received in cash from employer2018-12-31$697,472
Contract administrator fees2018-12-31$105,662
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-12-31No
Liabilities. Value of benefit claims payable at end of year2018-12-31$18,668
Liabilities. Value of benefit claims payable at beginning of year2018-12-31$7,086
Did the plan have assets held for investment2018-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31No
Opinion of an independent qualified public accountant for this plan2018-12-31Unqualified
Accountancy firm name2018-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2018-12-31251589048
2017 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets2017-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$7,086
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$22,653
Total income from all sources (including contributions)2017-12-31$901,418
Total loss/gain on sale of assets2017-12-31$0
Total of all expenses incurred2017-12-31$775,146
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2017-12-31$450,744
Total contributions o plan (from employers,participants, others, non cash contrinutions)2017-12-31$901,265
Value of total assets at end of year2017-12-31$145,874
Value of total assets at beginning of year2017-12-31$35,169
Total of administrative expenses incurred including professional, contract, advisory and management fees2017-12-31$324,402
Total interest from all sources2017-12-31$153
Total dividends received (eg from common stock, registered investment company shares)2017-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31Yes
Value of fidelity bond cover2017-12-31$260,000
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Contributions received from participants2017-12-31$304,116
Administrative expenses (other) incurred2017-12-31$204,655
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net income/loss2017-12-31$126,272
Value of net assets at end of year (total assets less liabilities)2017-12-31$138,788
Value of net assets at beginning of year (total assets less liabilities)2017-12-31$12,516
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Investment advisory and management fees2017-12-31$26,591
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2017-12-31$145,874
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2017-12-31$35,169
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2017-12-31$35,169
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2017-12-31$153
Expenses. Payments to insurance carriers foe the provision of benefits2017-12-31$450,744
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Contributions received in cash from employer2017-12-31$597,149
Contract administrator fees2017-12-31$93,156
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-12-31No
Liabilities. Value of benefit claims payable at end of year2017-12-31$7,086
Liabilities. Value of benefit claims payable at beginning of year2017-12-31$22,653
Did the plan have assets held for investment2017-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2017-12-31No
Opinion of an independent qualified public accountant for this plan2017-12-31Unqualified
Accountancy firm name2017-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2017-12-31251589048
2016 : STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets2016-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$22,653
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$0
Total income from all sources (including contributions)2016-12-31$218,126
Total loss/gain on sale of assets2016-12-31$0
Total of all expenses incurred2016-12-31$205,610
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2016-12-31$127,043
Total contributions o plan (from employers,participants, others, non cash contrinutions)2016-12-31$218,119
Value of total assets at end of year2016-12-31$35,169
Value of total assets at beginning of year2016-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2016-12-31$78,567
Total interest from all sources2016-12-31$7
Total dividends received (eg from common stock, registered investment company shares)2016-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-12-31No
Was this plan covered by a fidelity bond2016-12-31Yes
Value of fidelity bond cover2016-12-31$260,000
If this is an individual account plan, was there a blackout period2016-12-31No
Were there any nonexempt tranactions with any party-in-interest2016-12-31No
Contributions received from participants2016-12-31$68,714
Administrative expenses (other) incurred2016-12-31$49,510
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Value of net income/loss2016-12-31$12,516
Value of net assets at end of year (total assets less liabilities)2016-12-31$12,516
Value of net assets at beginning of year (total assets less liabilities)2016-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-12-31No
Were any leases to which the plan was party in default or uncollectible2016-12-31No
Investment advisory and management fees2016-12-31$22,720
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2016-12-31$35,169
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2016-12-31$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2016-12-31$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2016-12-31$7
Expenses. Payments to insurance carriers foe the provision of benefits2016-12-31$127,043
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-12-31No
Was there a failure to transmit to the plan any participant contributions2016-12-31No
Has the plan failed to provide any benefit when due under the plan2016-12-31No
Contributions received in cash from employer2016-12-31$149,405
Contract administrator fees2016-12-31$6,337
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32016-12-31No
Liabilities. Value of benefit claims payable at end of year2016-12-31$22,653
Liabilities. Value of benefit claims payable at beginning of year2016-12-31$0
Did the plan have assets held for investment2016-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2016-12-31No
Opinion of an independent qualified public accountant for this plan2016-12-31Unqualified
Accountancy firm name2016-12-31YOUNG, OAKES, BROWN & CO. P.C.
Accountancy firm EIN2016-12-31251589048

Form 5500 Responses for STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN

2022: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes
2018: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – TrustYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement - TrustYes
2017: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – TrustYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement - TrustYes
2016: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: STEVE SHANNON TIRE COMPANY, INC. HEALTH PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number30500225
Policy instance 1
Insurance contract or identification number30500225
Number of Individuals Covered179
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $450,493
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 number30500225
Policy instance 1
Insurance contract or identification number30500225
Number of Individuals Covered142
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $325,527
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 number30500225
Policy instance 1
Insurance contract or identification number30500225
Number of Individuals Covered142
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $276,318
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 number30500225
Policy instance 1
Insurance contract or identification number30500225
Number of Individuals Covered108
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $261,140
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 numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered120
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $204,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 2
Insurance contract or identification number0278900000
Number of Individuals Covered28
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $998
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $998
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 3
Insurance contract or identification number0278900000
Number of Individuals Covered28
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $550
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $550
Insurance broker nameBSI CORPORATE BENEFITS, LLC
GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )
Policy contract number117074
Policy instance 4
Insurance contract or identification number117074
Number of Individuals Covered136
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $23,865
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $596,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,865
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 5
Insurance contract or identification number0278900000
Number of Individuals Covered4
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,233
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCOMBO CANCER/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 CarrierUSD $1,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,233
Insurance broker nameBSI CORPORATE BENEFITS, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 1
Insurance contract or identification numberG000AD3K
Number of Individuals Covered10
Insurance policy start date2014-06-01
Insurance policy end date2015-06-01
Total amount of commissions paid to insurance brokerUSD $490
Total amount of fees paid to insurance companyUSD $280
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $490
Amount paid for insurance broker fees280
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameBSI CORPORATE BENEFITS LC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 3
Insurance contract or identification number0278900000
Number of Individuals Covered25
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $1,673
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,673
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 4
Insurance contract or identification number0278900000
Number of Individuals Covered23
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $573
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $573
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 5
Insurance contract or identification number0278900000
Number of Individuals Covered2
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $119
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCOMBO CANCER - 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 CarrierUSD $149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $119
Insurance broker nameBSI CORPORATE BENEFITS, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 2
Insurance contract or identification numberG000AD3K
Number of Individuals Covered111
Insurance policy start date2013-06-01
Insurance policy end date2014-06-01
Total amount of commissions paid to insurance brokerUSD $444
Total amount of fees paid to insurance companyUSD $253
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $444
Amount paid for insurance broker fees253
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameBSI CORPORATE BENEFITS LLC
GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )
Policy contract number117074
Policy instance 1
Insurance contract or identification number117074
Number of Individuals Covered192
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $22,035
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $417,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,035
Insurance broker nameBSI CORPORATE BENEFITS LLC
GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )
Policy contract number114218
Policy instance 1
Insurance contract or identification number114218
Number of Individuals Covered131
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $21,880
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $547,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,880
Insurance broker nameBSI CORP BENEFITS LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 3
Insurance contract or identification number0278900000
Number of Individuals Covered27
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $1,644
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,644
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 4
Insurance contract or identification number0278900000
Number of Individuals Covered25
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $537
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $537
Insurance broker nameBSI CORPORATE BENEFITS, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 2
Insurance contract or identification numberG000AD3K
Number of Individuals Covered116
Insurance policy start date2012-06-01
Insurance policy end date2013-06-01
Total amount of commissions paid to insurance brokerUSD $466
Total amount of fees paid to insurance companyUSD $223
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $466
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameBSI CORPORATE BENEFITS LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 2
Insurance contract or identification number0278900000
Number of Individuals Covered28
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $519
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $519
Insurance broker nameBSI CORPORATE BENEFITS, LLC
GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )
Policy contract number114218
Policy instance 3
Insurance contract or identification number114218
Number of Individuals Covered133
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $20,530
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $513,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,530
Insurance broker nameBSI CORP BENEFITS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 4
Insurance contract or identification numberG000AD3K
Number of Individuals Covered120
Insurance policy start date2011-06-01
Insurance policy end date2012-06-01
Total amount of commissions paid to insurance brokerUSD $551
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $551
Insurance broker nameBSI CORPORATE BENEFITS LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 1
Insurance contract or identification number0278900000
Number of Individuals Covered30
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,285
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,285
Insurance broker nameBSI CORPORATE BENEFITS, LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 1
Insurance contract or identification number0278900000
Number of Individuals Covered31
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,410
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 )
Policy contract number114218
Policy instance 2
Insurance contract or identification number114218
Number of Individuals Covered134
Insurance policy start date2011-10-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $5,096
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $127,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 )
Policy contract number00511317
Policy instance 3
Insurance contract or identification number00511317
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $17,231
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 4
Insurance contract or identification numberG000AD3K
Number of Individuals Covered110
Insurance policy start date2010-06-01
Insurance policy end date2011-06-01
Total amount of commissions paid to insurance brokerUSD $423
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
NATIONAL VISION ADMINISTRATORS, INC. (National Association of Insurance Commissioners NAIC id number: 66842 )
Policy contract number66842
Policy instance 2
Insurance contract or identification number66842
Number of Individuals Covered104
Insurance policy start date2010-10-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $63
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63
Insurance broker nameBSI CORPORATE BENEFITS, LLC
CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 )
Policy contract number00511317
Policy instance 1
Insurance contract or identification number00511317
Number of Individuals Covered104
Insurance policy start date2010-10-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $5,646
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,646
Insurance broker nameBSI CORPORATE BENEFITS, LLC
GEISINGER QUALITY OPTIONS, INC (National Association of Insurance Commissioners NAIC id number: 95923 )
Policy contract number100105
Policy instance 3
Insurance contract or identification number100105
Insurance policy start date2010-01-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $8,371
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $334,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,371
Insurance broker nameBSI CORP BENEFITS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AD3K
Policy instance 5
Insurance contract or identification numberG000AD3K
Number of Individuals Covered107
Insurance policy start date2009-06-01
Insurance policy end date2010-06-01
Total amount of commissions paid to insurance brokerUSD $420
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $420
Insurance broker nameBSI CORPORATE BENEFITS LLC
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number0278900000
Policy instance 4
Insurance contract or identification number0278900000
Number of Individuals Covered37
Insurance policy start date2009-09-01
Insurance policy end date2010-08-31
Total amount of commissions paid to insurance brokerUSD $5,022
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,022
Insurance broker nameBSI CORPORATE BENEFITS, LLC

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