ATLANTIC CARBON GROUP, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021 : COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-01-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-01-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-01-31 | $106,319 |
| Total income from all sources (including contributions) | 2021-01-31 | $2,604,735 |
| Total loss/gain on sale of assets | 2021-01-31 | $0 |
| Total of all expenses incurred | 2021-01-31 | $2,213,468 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-01-31 | $2,153,312 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-01-31 | $2,045,490 |
| Value of total assets at end of year | 2021-01-31 | $391,267 |
| Value of total assets at beginning of year | 2021-01-31 | $106,319 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-01-31 | $60,156 |
| Total interest from all sources | 2021-01-31 | $661 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-01-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-01-31 | No |
| Was this plan covered by a fidelity bond | 2021-01-31 | Yes |
| Value of fidelity bond cover | 2021-01-31 | $250,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2021-01-31 | No |
| Contributions received from participants | 2021-01-31 | $267,793 |
| Participant contributions at end of year | 2021-01-31 | $0 |
| Participant contributions at beginning of year | 2021-01-31 | $5,463 |
| Other income not declared elsewhere | 2021-01-31 | $558,584 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-01-31 | No |
| Value of net income/loss | 2021-01-31 | $391,267 |
| Value of net assets at end of year (total assets less liabilities) | 2021-01-31 | $391,267 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-01-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-01-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-01-31 | $391,267 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-01-31 | $69,901 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-01-31 | $69,901 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-01-31 | $661 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-01-31 | $431,390 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-01-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2021-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-01-31 | No |
| Contributions received in cash from employer | 2021-01-31 | $1,777,697 |
| Employer contributions (assets) at end of year | 2021-01-31 | $0 |
| Employer contributions (assets) at beginning of year | 2021-01-31 | $30,955 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-01-31 | $1,721,922 |
| Contract administrator fees | 2021-01-31 | $60,156 |
| Liabilities. Value of benefit claims payable at end of year | 2021-01-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-01-31 | $106,319 |
| Did the plan have assets held for investment | 2021-01-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-01-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-01-31 | Unqualified |
| Accountancy firm name | 2021-01-31 | KRONICK KALADA BERDY & CO., P.C. |
| Accountancy firm EIN | 2021-01-31 | 232667890 |
| 2020 : COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-01-31 | $0 |
| Total unrealized appreciation/depreciation of assets | 2020-01-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-01-31 | $106,319 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-01-31 | $106,319 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-01-31 | $112,023 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-01-31 | $112,023 |
| Total income from all sources (including contributions) | 2020-01-31 | $2,733,090 |
| Total income from all sources (including contributions) | 2020-01-31 | $2,733,090 |
| Total loss/gain on sale of assets | 2020-01-31 | $0 |
| Total loss/gain on sale of assets | 2020-01-31 | $0 |
| Total of all expenses incurred | 2020-01-31 | $2,733,090 |
| Total of all expenses incurred | 2020-01-31 | $2,733,090 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-01-31 | $2,607,352 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-01-31 | $2,607,352 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-01-31 | $2,022,907 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-01-31 | $2,022,907 |
| Value of total assets at end of year | 2020-01-31 | $106,319 |
| Value of total assets at end of year | 2020-01-31 | $106,319 |
| Value of total assets at beginning of year | 2020-01-31 | $112,023 |
| Value of total assets at beginning of year | 2020-01-31 | $112,023 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-01-31 | $125,738 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-01-31 | $125,738 |
| Total interest from all sources | 2020-01-31 | $137 |
| Total interest from all sources | 2020-01-31 | $137 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-01-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-01-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-01-31 | No |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-01-31 | No |
| Was this plan covered by a fidelity bond | 2020-01-31 | Yes |
| Was this plan covered by a fidelity bond | 2020-01-31 | Yes |
| Value of fidelity bond cover | 2020-01-31 | $250,000 |
| Value of fidelity bond cover | 2020-01-31 | $250,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2020-01-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-01-31 | No |
| Contributions received from participants | 2020-01-31 | $262,770 |
| Contributions received from participants | 2020-01-31 | $262,770 |
| Participant contributions at end of year | 2020-01-31 | $5,463 |
| Participant contributions at end of year | 2020-01-31 | $5,463 |
| Participant contributions at beginning of year | 2020-01-31 | $15,138 |
| Participant contributions at beginning of year | 2020-01-31 | $15,138 |
| Other income not declared elsewhere | 2020-01-31 | $710,046 |
| Other income not declared elsewhere | 2020-01-31 | $710,046 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-01-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-01-31 | No |
| Value of net income/loss | 2020-01-31 | $0 |
| Value of net income/loss | 2020-01-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2020-01-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2020-01-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-01-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-01-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-01-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-01-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-01-31 | $69,901 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-01-31 | $69,901 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-01-31 | $11,104 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-01-31 | $11,104 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-01-31 | $11,104 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-01-31 | $11,104 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-01-31 | $137 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-01-31 | $137 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-01-31 | $456,996 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-01-31 | $456,996 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-01-31 | Yes |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-01-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2020-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-01-31 | No |
| Contributions received in cash from employer | 2020-01-31 | $1,760,137 |
| Contributions received in cash from employer | 2020-01-31 | $1,760,137 |
| Employer contributions (assets) at end of year | 2020-01-31 | $30,955 |
| Employer contributions (assets) at end of year | 2020-01-31 | $30,955 |
| Employer contributions (assets) at beginning of year | 2020-01-31 | $85,781 |
| Employer contributions (assets) at beginning of year | 2020-01-31 | $85,781 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-01-31 | $2,150,356 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-01-31 | $2,150,356 |
| Contract administrator fees | 2020-01-31 | $125,738 |
| Contract administrator fees | 2020-01-31 | $125,738 |
| Liabilities. Value of benefit claims payable at end of year | 2020-01-31 | $106,319 |
| Liabilities. Value of benefit claims payable at end of year | 2020-01-31 | $106,319 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-01-31 | $112,023 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-01-31 | $112,023 |
| Did the plan have assets held for investment | 2020-01-31 | Yes |
| Did the plan have assets held for investment | 2020-01-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-01-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-01-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2020-01-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2020-01-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-01-31 | Unqualified |
| Opinion of an independent qualified public accountant for this plan | 2020-01-31 | Unqualified |
| Accountancy firm name | 2020-01-31 | KRONICK KALADA BERDY & CO., P.C. |
| Accountancy firm name | 2020-01-31 | KRONICK KALADA BERDY & CO., P.C. |
| Accountancy firm EIN | 2020-01-31 | 232667890 |
| Accountancy firm EIN | 2020-01-31 | 232667890 |
| 2019 : COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-01-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-01-31 | $112,023 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-01-31 | $85,746 |
| Total income from all sources (including contributions) | 2019-01-31 | $1,534,595 |
| Total loss/gain on sale of assets | 2019-01-31 | $0 |
| Total of all expenses incurred | 2019-01-31 | $1,548,068 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-01-31 | $1,418,335 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-01-31 | $1,534,432 |
| Value of total assets at end of year | 2019-01-31 | $112,023 |
| Value of total assets at beginning of year | 2019-01-31 | $99,219 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-01-31 | $129,733 |
| Total interest from all sources | 2019-01-31 | $163 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-01-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-01-31 | No |
| Was this plan covered by a fidelity bond | 2019-01-31 | Yes |
| Value of fidelity bond cover | 2019-01-31 | $250,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2019-01-31 | No |
| Contributions received from participants | 2019-01-31 | $230,165 |
| Participant contributions at end of year | 2019-01-31 | $15,138 |
| Participant contributions at beginning of year | 2019-01-31 | $14,038 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-01-31 | No |
| Value of net income/loss | 2019-01-31 | $-13,473 |
| Value of net assets at end of year (total assets less liabilities) | 2019-01-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-01-31 | $13,473 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-01-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-01-31 | $11,104 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-01-31 | $5,634 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-01-31 | $5,634 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2019-01-31 | $163 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-01-31 | $168,975 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-01-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2019-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-01-31 | No |
| Contributions received in cash from employer | 2019-01-31 | $1,304,267 |
| Employer contributions (assets) at end of year | 2019-01-31 | $85,781 |
| Employer contributions (assets) at beginning of year | 2019-01-31 | $79,547 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-01-31 | $1,249,360 |
| Contract administrator fees | 2019-01-31 | $129,733 |
| Liabilities. Value of benefit claims payable at end of year | 2019-01-31 | $112,023 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-01-31 | $85,746 |
| Did the plan have assets held for investment | 2019-01-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-01-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-01-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-01-31 | Unqualified |
| Accountancy firm name | 2019-01-31 | KRONICK KALADA BERDY & CO., P.C. |
| Accountancy firm EIN | 2019-01-31 | 232667890 |
| 2018 : COAL CONTRACTORS (1991), INC. EMPLOYEE BENEFIT PLAN 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-01-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-01-31 | $85,746 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-01-31 | $0 |
| Total income from all sources (including contributions) | 2018-01-31 | $1,386,238 |
| Total loss/gain on sale of assets | 2018-01-31 | $0 |
| Total of all expenses incurred | 2018-01-31 | $1,372,765 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-01-31 | $1,253,868 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-01-31 | $1,386,121 |
| Value of total assets at end of year | 2018-01-31 | $99,219 |
| Value of total assets at beginning of year | 2018-01-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-01-31 | $118,897 |
| Total interest from all sources | 2018-01-31 | $117 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-01-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-01-31 | No |
| Was this plan covered by a fidelity bond | 2018-01-31 | Yes |
| Value of fidelity bond cover | 2018-01-31 | $250,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2018-01-31 | No |
| Contributions received from participants | 2018-01-31 | $207,918 |
| Participant contributions at end of year | 2018-01-31 | $14,038 |
| Participant contributions at beginning of year | 2018-01-31 | $0 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-01-31 | No |
| Value of net income/loss | 2018-01-31 | $13,473 |
| Value of net assets at end of year (total assets less liabilities) | 2018-01-31 | $13,473 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-01-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-01-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-01-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-01-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2018-01-31 | $5,634 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2018-01-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2018-01-31 | $0 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2018-01-31 | $117 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-01-31 | $237,716 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-01-31 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2018-01-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-01-31 | No |
| Contributions received in cash from employer | 2018-01-31 | $1,178,203 |
| Employer contributions (assets) at end of year | 2018-01-31 | $79,547 |
| Employer contributions (assets) at beginning of year | 2018-01-31 | $0 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-01-31 | $1,016,152 |
| Contract administrator fees | 2018-01-31 | $118,897 |
| Liabilities. Value of benefit claims payable at end of year | 2018-01-31 | $85,746 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-01-31 | $0 |
| Did the plan have assets held for investment | 2018-01-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-01-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-01-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-01-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-01-31 | Unqualified |
| Accountancy firm name | 2018-01-31 | KRONICK KALADA BERDY & CO., P.C. |
| Accountancy firm EIN | 2018-01-31 | 232667890 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 62092 |
| Policy instance | 7 |
| Insurance contract or identification number | 62092 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | 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 | 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 | VOLUNTARY DEP LIFE CHILD | | 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 $236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 62092 |
| Policy instance | 6 |
| Insurance contract or identification number | 62092 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | 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 | 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 | VOLUNTARY DEP LIFE SPOUSE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 62092 |
| Policy instance | 5 |
| Insurance contract or identification number | 62092 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | 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 | 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 | VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 62092 |
| Policy instance | 4 |
| Insurance contract or identification number | 62092 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | 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 | 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 | VOLUNTARY LIFE | | 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 $14,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 62092 |
| Policy instance | 3 |
| Insurance contract or identification number | 62092 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $3,653 | | 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 | 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 $16,967 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $547 | | Additional information about fees paid to insurance broker | SALES AND SERVICE COMPENSATION | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 119991 |
| Policy instance | 2 |
| Insurance contract or identification number | 119991 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $34,282 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,902,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,054 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 252516-000 |
| Policy instance | 1 |
| Insurance contract or identification number | 252516-000 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2021-12-31 | | 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 | 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 $84,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 006660 |
| Policy instance | 3 |
| Insurance contract or identification number | 006660 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 252516-000 |
| Policy instance | 2 |
| Insurance contract or identification number | 252516-000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 | 30500265 |
| Policy instance | 1 |
| Insurance contract or identification number | 30500265 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $431,390 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 006660 |
| Policy instance | 3 |
| Insurance contract or identification number | 006660 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $74,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 252516-000 |
| Policy instance | 2 |
| Insurance contract or identification number | 252516-000 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,795 | | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 135 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $456,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 006660 |
| Policy instance | 3 |
| Insurance contract or identification number | 006660 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 252516-000 |
| Policy instance | 2 |
| Insurance contract or identification number | 252516-000 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 $57,176 | | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 117 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $320,502 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 0 |
| Policy instance | 3 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | 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 | VERIS |
| Policy instance | 1 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 106 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $314,873 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
