UNION-SNYDER AGENCY ON AGING, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 20 |
| Total of all active and inactive participants | 2021-01-01 | 0 |
| Total participants | 2021-01-01 | 0 |
| 2020: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 18 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 20 |
| 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 | 20 |
| 2019: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 23 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 18 |
| 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 | 18 |
| 2018: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 23 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 23 |
| 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 | 23 |
| Measure | Date | Value |
|---|
| 2021 : UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total plan liabilities at beginning of year | 2021-12-31 | $42,397 |
| Total income from all sources | 2021-12-31 | $321,994 |
| Expenses. Total of all expenses incurred | 2021-12-31 | $281,306 |
| Benefits paid (including direct rollovers) | 2021-12-31 | $276,108 |
| Total plan assets at end of year | 2021-12-31 | $0 |
| Total plan assets at beginning of year | 2021-12-31 | $1,709 |
| Value of fidelity bond covering the plan | 2021-12-31 | $120,000 |
| Total contributions received or receivable from participants | 2021-12-31 | $31,391 |
| Expenses. Other expenses not covered elsewhere | 2021-12-31 | $5,198 |
| Net income (gross income less expenses) | 2021-12-31 | $40,688 |
| Net plan assets at end of year (total assets less liabilities) | 2021-12-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2021-12-31 | $-40,688 |
| Total contributions received or receivable from employer(s) | 2021-12-31 | $290,603 |
| 2020 : UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total plan liabilities at end of year | 2020-12-31 | $42,397 |
| Total plan liabilities at beginning of year | 2020-12-31 | $34,914 |
| Total income from all sources | 2020-12-31 | $22,415 |
| Expenses. Total of all expenses incurred | 2020-12-31 | $32,508 |
| Benefits paid (including direct rollovers) | 2020-12-31 | $23,239 |
| Total plan assets at end of year | 2020-12-31 | $1,709 |
| Total plan assets at beginning of year | 2020-12-31 | $4,319 |
| Value of fidelity bond covering the plan | 2020-12-31 | $120,000 |
| Total contributions received or receivable from participants | 2020-12-31 | $2,053 |
| Expenses. Other expenses not covered elsewhere | 2020-12-31 | $8,729 |
| Other income received | 2020-12-31 | $3 |
| Net income (gross income less expenses) | 2020-12-31 | $-10,093 |
| Net plan assets at end of year (total assets less liabilities) | 2020-12-31 | $-40,688 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-12-31 | $-30,595 |
| Total contributions received or receivable from employer(s) | 2020-12-31 | $20,359 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-12-31 | $540 |
| Total plan liabilities at end of year | 2020-11-30 | $34,914 |
| Total plan liabilities at beginning of year | 2020-11-30 | $47,306 |
| Total income from all sources | 2020-11-30 | $287,108 |
| Expenses. Total of all expenses incurred | 2020-11-30 | $283,114 |
| Benefits paid (including direct rollovers) | 2020-11-30 | $163,734 |
| Total plan assets at end of year | 2020-11-30 | $4,319 |
| Total plan assets at beginning of year | 2020-11-30 | $12,717 |
| Value of fidelity bond covering the plan | 2020-11-30 | $120,000 |
| Total contributions received or receivable from participants | 2020-11-30 | $25,889 |
| Expenses. Other expenses not covered elsewhere | 2020-11-30 | $112,279 |
| Contributions received from other sources (not participants or employers) | 2020-11-30 | $7,572 |
| Other income received | 2020-11-30 | $81 |
| Net income (gross income less expenses) | 2020-11-30 | $3,994 |
| Net plan assets at end of year (total assets less liabilities) | 2020-11-30 | $-30,595 |
| Net plan assets at beginning of year (total assets less liabilities) | 2020-11-30 | $-34,589 |
| Total contributions received or receivable from employer(s) | 2020-11-30 | $253,566 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2020-11-30 | $7,101 |
| 2019 : UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2019 401k financial data |
|---|
| Total plan liabilities at end of year | 2019-11-30 | $47,306 |
| Total plan liabilities at beginning of year | 2019-11-30 | $0 |
| Total income from all sources | 2019-11-30 | $269,680 |
| Expenses. Total of all expenses incurred | 2019-11-30 | $304,269 |
| Benefits paid (including direct rollovers) | 2019-11-30 | $192,958 |
| Total plan assets at end of year | 2019-11-30 | $12,717 |
| Total plan assets at beginning of year | 2019-11-30 | $0 |
| Value of fidelity bond covering the plan | 2019-11-30 | $120,000 |
| Total contributions received or receivable from participants | 2019-11-30 | $26,582 |
| Expenses. Other expenses not covered elsewhere | 2019-11-30 | $107,655 |
| Contributions received from other sources (not participants or employers) | 2019-11-30 | $0 |
| Other income received | 2019-11-30 | $141 |
| Net income (gross income less expenses) | 2019-11-30 | $-34,589 |
| Net plan assets at end of year (total assets less liabilities) | 2019-11-30 | $-34,589 |
| Net plan assets at beginning of year (total assets less liabilities) | 2019-11-30 | $0 |
| Total contributions received or receivable from employer(s) | 2019-11-30 | $242,957 |
| Value of corrective distributions | 2019-11-30 | $0 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2019-11-30 | $3,656 |
| 2021: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | This submission is the final filing | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – Trust | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement - Trust | Yes |
| 2020: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – Trust | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement - Trust | Yes |
| 2019: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | No |
| 2019-12-01 | This submission is the final filing | No |
| 2019-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-01 | Plan is a collectively bargained plan | No |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – Trust | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement - Trust | Yes |
| 2018: UNION-SNYDER AGENCY ON AGING, INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | First time form 5500 has been submitted | Yes |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – Trust | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement - Trust | Yes |
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 000023 |
| Policy instance | 3 |
| Insurance contract or identification number | 000023 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 258118001 |
| Policy instance | 2 |
| Insurance contract or identification number | 258118001 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 1 |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | 30700022 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 000023 |
| Policy instance | 3 |
| Insurance contract or identification number | 000023 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $21 | | 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 $172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $21 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 258118001 |
| Policy instance | 2 |
| Insurance contract or identification number | 258118001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $62 | | 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 $614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | 30700022 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700022 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 000023 |
| Policy instance | 3 |
| Insurance contract or identification number | 000023 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $239 | | 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 $2,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $239 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 258118001 |
| Policy instance | 2 |
| Insurance contract or identification number | 258118001 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $672 | | 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 $7,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $672 | | Insurance broker organization code? | 3 |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | 30700022 |
| Policy instance | 1 |
| Insurance contract or identification number | 30700022 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | 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 $97,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 000023 |
| Policy instance | 3 |
| Insurance contract or identification number | 000023 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $270 | | Total amount of fees paid to insurance company | USD $60 | | 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 $2,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $270 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | BASIC / PREMIER |
| Policy instance | 2 |
| Insurance contract or identification number | BASIC / PREMIER | | Number of Individuals Covered | 10 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $705 | | 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 $6,787 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $705 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NONE | | Insurance broker organization code? | 3 |
|
| EXCESS REINSURANCE UNDERWRITERS (National Association of Insurance Commissioners NAIC id number: 26921 ) |
| Policy contract number | PCI |
| Policy instance | 1 |
| Insurance contract or identification number | PCI | | Number of Individuals Covered | 23 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | 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 $92,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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