XYLEM I LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan XYLEM TREE EXPERTS HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2021: XYLEM TREE EXPERTS HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 381 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 172 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 172 |
| Number of employers contributing to the scheme | 2021-12-01 | 0 |
| 2020: XYLEM TREE EXPERTS HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 381 |
| 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 | 381 |
| Number of employers contributing to the scheme | 2020-12-01 | 0 |
| 2019: XYLEM TREE EXPERTS HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 212 |
| 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 | 212 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3344664 |
| Policy instance | 1 |
| Insurance contract or identification number | 3344664 | | Number of Individuals Covered | 404 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $155,401 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,750,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $155,401 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 50007221001 |
| Policy instance | 2 |
| Insurance contract or identification number | 50007221001 | | Number of Individuals Covered | 479 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,528 | | 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 | 1D041521 |
| Policy instance | 3 |
| Insurance contract or identification number | 1D041521 | | Number of Individuals Covered | 385 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $139,232 | | Total amount of fees paid to insurance company | USD $54,939 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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,CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $521,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,454 | | Amount paid for insurance broker fees | 32916 | | Additional information about fees paid to insurance broker | OVERRIDES, BROKER BONUS, OVERRIDES | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 ) |
| Policy contract number | L01303 |
| Policy instance | 1 |
| Insurance contract or identification number | L01303 | | Number of Individuals Covered | 375 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $108,300 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,802,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,870 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1119920 |
| Policy instance | 2 |
| Insurance contract or identification number | 1119920 | | Number of Individuals Covered | 503 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $43,292 | | Total amount of fees paid to insurance company | USD $27,369 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $332,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 27225 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE EXPENSE BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $21,865 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910987 |
| Policy instance | 1 |
| Insurance contract or identification number | 910987 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $236 | | Total amount of fees paid to insurance company | USD $36,968 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1119920 |
| Policy instance | 2 |
| Insurance contract or identification number | 1119920 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $21,838 | | Total amount of fees paid to insurance company | USD $11,105 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $109,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
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