MAPLE DONUTS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN
401k plan membership statisitcs for MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN
| Measure | Date | Value |
|---|
| 2021: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 253 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 254 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 255 |
| 2020: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 301 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 252 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 253 |
| 2019: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 302 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 299 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 301 |
| 2018: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 306 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 300 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 302 |
| 2017: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 320 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 305 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 306 |
| 2016: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 380 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 320 |
| Total of all active and inactive participants | 2016-10-01 | 320 |
| 2015: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 350 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 380 |
| Total of all active and inactive participants | 2015-10-01 | 380 |
| 2014: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 355 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 350 |
| Total of all active and inactive participants | 2014-10-01 | 350 |
| 2013: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 321 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 355 |
| Total of all active and inactive participants | 2013-10-01 | 355 |
| 2012: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 279 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 321 |
| Total of all active and inactive participants | 2012-10-01 | 321 |
| 2011: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 164 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 176 |
| Total of all active and inactive participants | 2011-10-01 | 176 |
| 2009: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 254 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 246 |
| Total of all active and inactive participants | 2009-10-01 | 246 |
| Measure | Date | Value |
|---|
| 2022 : MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2022 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2022-09-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-09-30 | $390,489 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-09-30 | $258,692 |
| Total income from all sources (including contributions) | 2022-09-30 | $1,783,005 |
| Total loss/gain on sale of assets | 2022-09-30 | $0 |
| Total of all expenses incurred | 2022-09-30 | $1,809,315 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-09-30 | $1,670,186 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-09-30 | $1,783,005 |
| Value of total assets at end of year | 2022-09-30 | $123,748 |
| Value of total assets at beginning of year | 2022-09-30 | $18,261 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-09-30 | $139,129 |
| Total interest from all sources | 2022-09-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-09-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-09-30 | No |
| Administrative expenses professional fees incurred | 2022-09-30 | $139,129 |
| Was this plan covered by a fidelity bond | 2022-09-30 | Yes |
| Value of fidelity bond cover | 2022-09-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2022-09-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-09-30 | No |
| Contributions received from participants | 2022-09-30 | $342,044 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-09-30 | $74,852 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-09-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-09-30 | $128,503 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-09-30 | $0 |
| Total non interest bearing cash at end of year | 2022-09-30 | $40,823 |
| Total non interest bearing cash at beginning of year | 2022-09-30 | $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 | 2022-09-30 | No |
| Value of net income/loss | 2022-09-30 | $-26,310 |
| Value of net assets at end of year (total assets less liabilities) | 2022-09-30 | $-266,741 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-09-30 | $-240,431 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-09-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-09-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-09-30 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2022-09-30 | $8,073 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2022-09-30 | $18,261 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2022-09-30 | $18,261 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-09-30 | $517,588 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-09-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2022-09-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-09-30 | No |
| Contributions received in cash from employer | 2022-09-30 | $1,440,961 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-09-30 | $1,152,598 |
| Liabilities. Value of benefit claims payable at end of year | 2022-09-30 | $261,986 |
| Liabilities. Value of benefit claims payable at beginning of year | 2022-09-30 | $254,388 |
| Did the plan have assets held for investment | 2022-09-30 | 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 | 2022-09-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-09-30 | No |
| Liabilities. Value of acquisition indebtedness at end of year | 2022-09-30 | $0 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2022-09-30 | $4,304 |
| Opinion of an independent qualified public accountant for this plan | 2022-09-30 | Unqualified |
| Accountancy firm name | 2022-09-30 | RKL LLP |
| Accountancy firm EIN | 2022-09-30 | 232108173 |
| 2021 : MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-09-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-09-30 | $258,692 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-09-30 | $264,246 |
| Total income from all sources (including contributions) | 2021-09-30 | $1,916,630 |
| Total loss/gain on sale of assets | 2021-09-30 | $0 |
| Total of all expenses incurred | 2021-09-30 | $1,931,938 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-09-30 | $1,740,175 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-09-30 | $1,916,630 |
| Value of total assets at end of year | 2021-09-30 | $18,261 |
| Value of total assets at beginning of year | 2021-09-30 | $39,123 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-09-30 | $191,763 |
| Total interest from all sources | 2021-09-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-09-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-09-30 | No |
| Administrative expenses professional fees incurred | 2021-09-30 | $191,763 |
| Was this plan covered by a fidelity bond | 2021-09-30 | Yes |
| Value of fidelity bond cover | 2021-09-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2021-09-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-09-30 | No |
| Contributions received from participants | 2021-09-30 | $367,258 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2021-09-30 | $1,549,372 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-09-30 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-09-30 | $27,986 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-09-30 | No |
| Value of net income/loss | 2021-09-30 | $-15,308 |
| Value of net assets at end of year (total assets less liabilities) | 2021-09-30 | $-240,431 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-09-30 | $-225,123 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-09-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-09-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-09-30 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-09-30 | $18,261 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-09-30 | $11,137 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-09-30 | $11,137 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-09-30 | $560,272 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-09-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2021-09-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-09-30 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-09-30 | $1,179,903 |
| Liabilities. Value of benefit claims payable at end of year | 2021-09-30 | $254,388 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-09-30 | $264,246 |
| Did the plan have assets held for investment | 2021-09-30 | 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 | 2021-09-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-09-30 | No |
| Liabilities. Value of acquisition indebtedness at end of year | 2021-09-30 | $4,304 |
| Liabilities. Value of acquisition indebtedness at beginning of year | 2021-09-30 | $0 |
| Opinion of an independent qualified public accountant for this plan | 2021-09-30 | Unqualified |
| Accountancy firm name | 2021-09-30 | RKL LLP |
| Accountancy firm EIN | 2021-09-30 | 232108173 |
| 2020 : MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-09-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-09-30 | $264,246 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-09-30 | $111,807 |
| Total income from all sources (including contributions) | 2020-09-30 | $2,074,823 |
| Total loss/gain on sale of assets | 2020-09-30 | $0 |
| Total of all expenses incurred | 2020-09-30 | $2,206,940 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-09-30 | $2,013,445 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-09-30 | $2,074,823 |
| Value of total assets at end of year | 2020-09-30 | $39,123 |
| Value of total assets at beginning of year | 2020-09-30 | $18,801 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-09-30 | $193,495 |
| Total interest from all sources | 2020-09-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-09-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-09-30 | No |
| Administrative expenses professional fees incurred | 2020-09-30 | $193,495 |
| Was this plan covered by a fidelity bond | 2020-09-30 | Yes |
| Value of fidelity bond cover | 2020-09-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2020-09-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-09-30 | No |
| Contributions received from participants | 2020-09-30 | $399,224 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2020-09-30 | $1,675,599 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-09-30 | $27,986 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-09-30 | $1,028 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-09-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-09-30 | $2,632 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-09-30 | No |
| Value of net income/loss | 2020-09-30 | $-132,117 |
| Value of net assets at end of year (total assets less liabilities) | 2020-09-30 | $-225,123 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-09-30 | $-93,006 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-09-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-09-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-09-30 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-09-30 | $11,137 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-09-30 | $17,773 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-09-30 | $17,773 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-09-30 | $622,222 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-09-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2020-09-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-09-30 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-09-30 | $1,391,223 |
| Liabilities. Value of benefit claims payable at end of year | 2020-09-30 | $264,246 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-09-30 | $109,175 |
| Did the plan have assets held for investment | 2020-09-30 | 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 | 2020-09-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-09-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2020-09-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-09-30 | Unqualified |
| Accountancy firm name | 2020-09-30 | RKL LLP |
| Accountancy firm EIN | 2020-09-30 | 232108173 |
| 2019 : MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-09-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-09-30 | $111,807 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-09-30 | $0 |
| Total income from all sources (including contributions) | 2019-09-30 | $1,959,375 |
| Total loss/gain on sale of assets | 2019-09-30 | $0 |
| Total of all expenses incurred | 2019-09-30 | $2,052,381 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-09-30 | $1,854,700 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-09-30 | $1,959,317 |
| Value of total assets at end of year | 2019-09-30 | $18,801 |
| Value of total assets at beginning of year | 2019-09-30 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-09-30 | $197,681 |
| Total interest from all sources | 2019-09-30 | $58 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-09-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-09-30 | No |
| Administrative expenses professional fees incurred | 2019-09-30 | $197,681 |
| Was this plan covered by a fidelity bond | 2019-09-30 | Yes |
| Value of fidelity bond cover | 2019-09-30 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2019-09-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-09-30 | No |
| Contributions received from participants | 2019-09-30 | $393,756 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2019-09-30 | $1,565,561 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-09-30 | $1,028 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-09-30 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-09-30 | $2,632 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-09-30 | $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 | 2019-09-30 | No |
| Value of net income/loss | 2019-09-30 | $-93,006 |
| Value of net assets at end of year (total assets less liabilities) | 2019-09-30 | $-93,006 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-09-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-09-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-09-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-09-30 | No |
| Income. Interest from US Government securities | 2019-09-30 | $58 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-09-30 | $17,773 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-09-30 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-09-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-09-30 | $618,099 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-09-30 | Yes |
| Was there a failure to transmit to the plan any participant contributions | 2019-09-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-09-30 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-09-30 | $1,236,601 |
| Liabilities. Value of benefit claims payable at end of year | 2019-09-30 | $109,175 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-09-30 | $0 |
| Did the plan have assets held for investment | 2019-09-30 | 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 | 2019-09-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-09-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-09-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-09-30 | Unqualified |
| Accountancy firm name | 2019-09-30 | RKL LLP |
| Accountancy firm EIN | 2019-09-30 | 232108173 |
| 2021: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Submission has been amended | No |
| 2021-10-01 | This submission is the final filing | No |
| 2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-10-01 | Plan is a collectively bargained plan | No |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – Trust | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement - Trust | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Submission has been amended | No |
| 2020-10-01 | This submission is the final filing | No |
| 2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-10-01 | Plan is a collectively bargained plan | No |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – Trust | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement - Trust | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Submission has been amended | No |
| 2019-10-01 | This submission is the final filing | No |
| 2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-10-01 | Plan is a collectively bargained plan | No |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – Trust | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement - Trust | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Submission has been amended | No |
| 2018-10-01 | This submission is the final filing | No |
| 2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-10-01 | Plan is a collectively bargained plan | No |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – Trust | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement - Trust | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: MAPLE DONUTS, INC. HEALTH BENEFITS TAX SAVINGS PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500372 |
| Policy instance | 6 |
| Insurance contract or identification number | 30500372 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $333,558 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010083646 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010083646 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,527 | | 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 | Yes | | 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 $10,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,527 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031417 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010031417 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,262 | | 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 | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,262 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031418 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010031418 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,633 | | 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 | Yes | | 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 $98,206 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,633 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759632 |
| Policy instance | 2 |
| Insurance contract or identification number | 759632 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,822 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,822 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759632 |
| Policy instance | 1 |
| Insurance contract or identification number | 759632 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $416 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $416 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500372 |
| Policy instance | 6 |
| Insurance contract or identification number | 30500372 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $359,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759632 |
| Policy instance | 1 |
| Insurance contract or identification number | 759632 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,370 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,370 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759632 |
| Policy instance | 2 |
| Insurance contract or identification number | 759632 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $7,152 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,152 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031418 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010031418 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,652 | | 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 | Yes | | 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 $99,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,652 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031417 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010031417 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,352 | | 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 | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,352 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010083646 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010083646 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,511 | | 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 | Yes | | 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 $10,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,511 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 30500372 |
| Policy instance | 6 |
| Insurance contract or identification number | 30500372 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $376,054 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010083646 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010083646 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,540 | | 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 | Yes | | 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 $10,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,540 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031417 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010031417 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,415 | | 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 | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,415 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031418 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010031418 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $3,715 | | 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 | Yes | | 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 $105,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,715 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470635 |
| Policy instance | 2 |
| Insurance contract or identification number | 00470635 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $4,745 | | 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 $94,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,745 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 071031 |
| Policy instance | 1 |
| Insurance contract or identification number | 071031 | | Number of Individuals Covered | 351 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $584 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $584 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470635 |
| Policy instance | 2 |
| Insurance contract or identification number | 00470635 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $5,585 | | 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 $111,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,585 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 071031 |
| Policy instance | 1 |
| Insurance contract or identification number | 071031 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $568 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $568 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031418 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010031418 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $3,753 | | 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 | Yes | | 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 $109,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,753 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031417 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010031417 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,466 | | 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 | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,203 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,466 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010083646 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010083646 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,620 | | 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 | Yes | | 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 $10,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,620 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | VERIS |
| Policy instance | 6 |
| Insurance contract or identification number | VERIS | | Number of Individuals Covered | 203 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $367,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010083646 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010083646 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,005 | | Total amount of fees paid to insurance company | USD $133 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031417 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010031417 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,566 | | Total amount of fees paid to insurance company | USD $266 | | 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 | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010031418 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010031418 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $3,498 | | Total amount of fees paid to insurance company | USD $1,594 | | 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 | Yes | | 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 $89,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470635 |
| Policy instance | 2 |
| Insurance contract or identification number | 00470635 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,974 | | 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 $99,488 | | 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 | 02559998 |
| Policy instance | 1 |
| Insurance contract or identification number | 02559998 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $64,003 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $1,598,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
