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CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameCPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN
Plan identification number 501

CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

CPA PAVEMENT SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name:CPA PAVEMENT SERVICES, INC.
Employer identification number (EIN):275300679
NAIC Classification:238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-07-01
5012020-07-01
5012019-07-01
5012018-07-01
5012018-06-01KEVIN ZAKIS

Plan Statistics for CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2021: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-0137
Total number of active participants reported on line 7a of the Form 55002021-07-0143
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-0143
2020: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-0145
Total number of active participants reported on line 7a of the Form 55002020-07-0137
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-0137
2019: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-0142
Total number of active participants reported on line 7a of the Form 55002019-07-0145
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-0145
2018: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-0142
Total number of active participants reported on line 7a of the Form 55002018-07-0142
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-0142
Total participants, beginning-of-year2018-06-0142
Total number of active participants reported on line 7a of the Form 55002018-06-0142
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-0142

Financial Data on CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022 : CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2022 401k financial data
Total plan liabilities at end of year2022-06-30$34,619
Total plan liabilities at beginning of year2022-06-30$25,978
Total income from all sources2022-06-30$384,748
Expenses. Total of all expenses incurred2022-06-30$401,169
Benefits paid (including direct rollovers)2022-06-30$260,516
Total plan assets at end of year2022-06-30$0
Total plan assets at beginning of year2022-06-30$7,780
Value of fidelity bond covering the plan2022-06-30$20,000
Total contributions received or receivable from participants2022-06-30$0
Expenses. Other expenses not covered elsewhere2022-06-30$135,737
Contributions received from other sources (not participants or employers)2022-06-30$0
Other income received2022-06-30$36
Net income (gross income less expenses)2022-06-30$-16,421
Net plan assets at end of year (total assets less liabilities)2022-06-30$-34,619
Net plan assets at beginning of year (total assets less liabilities)2022-06-30$-18,198
Total contributions received or receivable from employer(s)2022-06-30$384,712
Value of corrective distributions2022-06-30$0
Expenses. Administrative service providers (salaries,fees and commissions)2022-06-30$4,916
2021 : CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data
Total plan liabilities at end of year2021-06-30$25,978
Total plan liabilities at beginning of year2021-06-30$110,796
Total income from all sources2021-06-30$346,917
Expenses. Total of all expenses incurred2021-06-30$314,612
Benefits paid (including direct rollovers)2021-06-30$177,884
Total plan assets at end of year2021-06-30$7,780
Total plan assets at beginning of year2021-06-30$60,293
Value of fidelity bond covering the plan2021-06-30$20,000
Total contributions received or receivable from participants2021-06-30$0
Expenses. Other expenses not covered elsewhere2021-06-30$125,807
Contributions received from other sources (not participants or employers)2021-06-30$0
Other income received2021-06-30$40
Net income (gross income less expenses)2021-06-30$32,305
Net plan assets at end of year (total assets less liabilities)2021-06-30$-18,198
Net plan assets at beginning of year (total assets less liabilities)2021-06-30$-50,503
Total contributions received or receivable from employer(s)2021-06-30$346,877
Value of corrective distributions2021-06-30$0
Expenses. Administrative service providers (salaries,fees and commissions)2021-06-30$10,921
2020 : CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data
Total plan liabilities at end of year2020-06-30$110,796
Total plan liabilities at beginning of year2020-06-30$1,907
Total income from all sources2020-06-30$297,671
Expenses. Total of all expenses incurred2020-06-30$346,547
Benefits paid (including direct rollovers)2020-06-30$205,083
Total plan assets at end of year2020-06-30$60,293
Total plan assets at beginning of year2020-06-30$280
Value of fidelity bond covering the plan2020-06-30$20,000
Total contributions received or receivable from participants2020-06-30$0
Expenses. Other expenses not covered elsewhere2020-06-30$130,296
Contributions received from other sources (not participants or employers)2020-06-30$0
Other income received2020-06-30$18
Net income (gross income less expenses)2020-06-30$-48,876
Net plan assets at end of year (total assets less liabilities)2020-06-30$-50,503
Net plan assets at beginning of year (total assets less liabilities)2020-06-30$-1,627
Total contributions received or receivable from employer(s)2020-06-30$297,653
Value of corrective distributions2020-06-30$0
Expenses. Administrative service providers (salaries,fees and commissions)2020-06-30$11,168
2019 : CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data
Total plan liabilities at end of year2019-06-30$1,907
Total plan liabilities at beginning of year2019-06-30$2,458
Total income from all sources2019-06-30$250,514
Expenses. Total of all expenses incurred2019-06-30$258,544
Benefits paid (including direct rollovers)2019-06-30$139,844
Total plan assets at end of year2019-06-30$280
Total plan assets at beginning of year2019-06-30$8,861
Value of fidelity bond covering the plan2019-06-30$20,000
Expenses. Other expenses not covered elsewhere2019-06-30$109,852
Other income received2019-06-30$45
Net income (gross income less expenses)2019-06-30$-8,030
Net plan assets at end of year (total assets less liabilities)2019-06-30$-1,627
Net plan assets at beginning of year (total assets less liabilities)2019-06-30$6,403
Total contributions received or receivable from employer(s)2019-06-30$250,469
Expenses. Administrative service providers (salaries,fees and commissions)2019-06-30$8,848
2018 : CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2018 401k financial data
Total plan liabilities at end of year2018-06-30$2,458
Total plan liabilities at beginning of year2018-06-30$0
Total income from all sources2018-06-30$22,145
Expenses. Total of all expenses incurred2018-06-30$15,742
Benefits paid (including direct rollovers)2018-06-30$5,694
Total plan assets at end of year2018-06-30$8,861
Total plan assets at beginning of year2018-06-30$0
Value of fidelity bond covering the plan2018-06-30$20,000
Expenses. Other expenses not covered elsewhere2018-06-30$10,048
Other income received2018-06-30$1
Net income (gross income less expenses)2018-06-30$6,403
Net plan assets at end of year (total assets less liabilities)2018-06-30$6,403
Net plan assets at beginning of year (total assets less liabilities)2018-06-30$0
Total contributions received or receivable from employer(s)2018-06-30$22,144

Form 5500 Responses for CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN

2021: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – TrustYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement - TrustYes
2020: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – TrustYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement - TrustYes
2019: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – TrustYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement - TrustYes
2018: CPA PAVEMENT SERVICES, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Submission has been amendedNo
2018-07-01This submission is the final filingNo
2018-07-01This return/report is a short plan year return/report (less than 12 months)No
2018-07-01Plan is a collectively bargained planNo
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – TrustYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement - TrustYes
2018-06-01Type of plan entitySingle employer plan
2018-06-01First time form 5500 has been submittedYes
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – TrustYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number607705
Policy instance 3
Insurance contract or identification number607705
Number of Individuals Covered43
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $4,335
Total amount of fees paid to insurance companyUSD $269
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $35,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,335
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number607705
Policy instance 2
Insurance contract or identification number607705
Number of Individuals Covered28
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $133
Total amount of fees paid to insurance companyUSD $26
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $133
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number31000006
Policy instance 1
Insurance contract or identification number31000006
Number of Individuals Covered35
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $106,625
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 number00405267
Policy instance 2
Insurance contract or identification number00405267
Number of Individuals Covered29
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $1,726
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,726
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number2009
Policy instance 3
Insurance contract or identification number2009
Number of Individuals Covered29
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $164
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $164
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number31000006
Policy instance 1
Insurance contract or identification number31000006
Number of Individuals Covered37
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $96,958
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 number607705
Policy instance 4
Insurance contract or identification number607705
Number of Individuals Covered0
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number2009
Policy instance 3
Insurance contract or identification number2009
Number of Individuals Covered29
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $202
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $202
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number607705
Policy instance 4
Insurance contract or identification number607705
Number of Individuals Covered45
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $4,271
Total amount of fees paid to insurance companyUSD $263
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $35,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,271
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number31000006
Policy instance 1
Insurance contract or identification number31000006
Number of Individuals Covered38
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $100,968
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 number00405267
Policy instance 2
Insurance contract or identification number00405267
Number of Individuals Covered28
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $1,724
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,724
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number0
Policy instance 4
Insurance contract or identification number0
Number of Individuals Covered0
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number0
Policy instance 3
Insurance contract or identification number0
Number of Individuals Covered0
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00405267
Policy instance 2
Insurance contract or identification number00405267
Number of Individuals Covered28
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $1,589
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,589
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNONE
Insurance broker organization code?3
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered37
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $80,489
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 number0
Policy instance 4
Insurance contract or identification number0
Number of Individuals Covered0
Insurance policy start date2018-06-01
Insurance policy end date2018-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )
Policy contract number0
Policy instance 3
Insurance contract or identification number0
Number of Individuals Covered0
Insurance policy start date2018-06-01
Insurance policy end date2018-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number0
Policy instance 2
Insurance contract or identification number0
Number of Individuals Covered0
Insurance policy start date2018-06-01
Insurance policy end date2018-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered42
Insurance policy start date2018-06-01
Insurance policy end date2018-06-30
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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