SWEETGREEN, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SWEETGREEN, INC. HEALTH & WELFARE PLAN
401k plan membership statisitcs for SWEETGREEN, INC. HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 720 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 1,246 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 1,246 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 687 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 709 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 720 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 619 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 687 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 687 |
| Number of employers contributing to the scheme | 2020-12-01 | 0 |
| 2019: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 619 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 687 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 687 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2018: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 359 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 619 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 619 |
| Number of employers contributing to the scheme | 2018-12-01 | 0 |
| 2017: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 369 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 359 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 359 |
| Number of employers contributing to the scheme | 2017-12-01 | 0 |
| 2016: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 177 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 369 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 369 |
| 2015: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 173 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 177 |
| 2022: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: SWEETGREEN, INC. HEALTH & WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | First time form 5500 has been submitted | Yes |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL162904 |
| Policy instance | 5 |
| Insurance contract or identification number | GL162904 | | Number of Individuals Covered | 1246 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $79,140 | | Total amount of fees paid to insurance company | USD $28,712 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $589,980 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,140 | | Amount paid for insurance broker fees | 28712 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 4 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 1164 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $33,086 | | Total amount of fees paid to insurance company | USD $10,207 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,176,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,086 | | Amount paid for insurance broker fees | 10207 | | Additional information about fees paid to insurance broker | 2021 PINNACLE DENTAL NEW BUSINESS INCENTIVE RISK | | Insurance broker organization code? | 3 |
|
| COUNSELING GLOBAL DOMESTIC (National Association of Insurance Commissioners NAIC id number: 54161 ) |
| Policy contract number | 184038028 |
| Policy instance | 3 |
| Insurance contract or identification number | 184038028 | | Number of Individuals Covered | 4667 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $48,723 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30109055 |
| Policy instance | 2 |
| Insurance contract or identification number | 30109055 | | Number of Individuals Covered | 625 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,156 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,156 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 773421HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 773421HNO | | Number of Individuals Covered | 63 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $450 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $240,854 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $450 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 773421HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 773421HNO | | Number of Individuals Covered | 44 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,134 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,134 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30021130 |
| Policy instance | 2 |
| Insurance contract or identification number | 30021130 | | Number of Individuals Covered | 622 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,315 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,417 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COUNSELING GLOBAL DOMESTIC (National Association of Insurance Commissioners NAIC id number: 54161 ) |
| Policy contract number | 184038028 |
| Policy instance | 3 |
| Insurance contract or identification number | 184038028 | | Number of Individuals Covered | 4667 | | Insurance policy start date | 2021-01-01 | | 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 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $43,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 4 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 1180 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $221,747 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,185,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $221,747 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL162904 |
| Policy instance | 5 |
| Insurance contract or identification number | GL162904 | | Number of Individuals Covered | 864 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $68,177 | | Total amount of fees paid to insurance company | USD $25,928 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $502,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,177 | | Amount paid for insurance broker fees | 25928 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 1 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 1119 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $-210 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $573,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-210 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30021130 |
| Policy instance | 2 |
| Insurance contract or identification number | 30021130 | | Number of Individuals Covered | 569 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $176 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $176 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 554733 |
| Policy instance | 3 |
| Insurance contract or identification number | 554733 | | Number of Individuals Covered | 778 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $-1 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL | | 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 $-1 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 617640 |
| Policy instance | 4 |
| Insurance contract or identification number | 617640 | | Number of Individuals Covered | 936 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $219 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $219 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 617640 |
| Policy instance | 4 |
| Insurance contract or identification number | 617640 | | Number of Individuals Covered | 1079 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $395 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $3,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $395 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 554733 |
| Policy instance | 3 |
| Insurance contract or identification number | 554733 | | Number of Individuals Covered | 775 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $80,660 | | Total amount of fees paid to insurance company | USD $962 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $661,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $80,660 | | Amount paid for insurance broker fees | 962 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 1 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 1157 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $282,191 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,401,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $282,191 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30021130 |
| Policy instance | 2 |
| Insurance contract or identification number | 30021130 | | Number of Individuals Covered | 559 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $2,299 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,299 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 1 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 849 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $168,466 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,531,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $168,466 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30021130 |
| Policy instance | 2 |
| Insurance contract or identification number | 30021130 | | Number of Individuals Covered | 486 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,932 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,932 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 554733 |
| Policy instance | 3 |
| Insurance contract or identification number | 554733 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $34,186 | | Total amount of fees paid to insurance company | USD $3,820 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $473,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,467 | | Amount paid for insurance broker fees | 3820 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| AETNA EMPLOYEE ASSISTANCE PLAN (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 617640 |
| Policy instance | 4 |
| Insurance contract or identification number | 617640 | | Number of Individuals Covered | 2999 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $42,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 879574 |
| Policy instance | 5 |
| Insurance contract or identification number | 879574 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $10,987 | | Total amount of fees paid to insurance company | USD $813 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $63,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 879575 |
| Policy instance | 4 |
| Insurance contract or identification number | 879575 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $15,220 | | Total amount of fees paid to insurance company | USD $1,176 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,111 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | G0737 |
| Policy instance | 3 |
| Insurance contract or identification number | G0737 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $4,282 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $18,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30021130 |
| Policy instance | 2 |
| Insurance contract or identification number | 30021130 | | Number of Individuals Covered | 288 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,517 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 773421 |
| Policy instance | 1 |
| Insurance contract or identification number | 773421 | | Number of Individuals Covered | 507 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $124,525 | | Total amount of fees paid to insurance company | USD $7,320 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,543,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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