DAYTON SUPERIOR CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DAYTON SUPERIOR HEALTH BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2023: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 600 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 588 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 588 |
| 2022: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 597 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 594 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 6 |
| 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 | 600 |
| 2021: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 594 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 591 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 6 |
| 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 | 597 |
| 2020: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 765 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 581 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 594 |
| 2019: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 790 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 728 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 37 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 765 |
| 2018: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 1,053 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 829 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 49 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 878 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 1,111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,015 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 38 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 1,053 |
| 2016: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 1,151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 1,089 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 22 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 1,111 |
| 2015: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 1,148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 1,136 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 15 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 1,151 |
| 2014: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 824 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 1,147 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 1,148 |
| 2013: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 1,033 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 797 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 27 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 824 |
| 2012: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 1,049 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 1,033 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 60 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 1,093 |
| 2011: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 1,138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 1,049 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 74 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 1,123 |
| 2009: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 1,287 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 985 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 92 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 1,077 |
| 2023: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | No |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | No |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 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: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 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: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: DAYTON SUPERIOR HEALTH BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | Yes |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 895168G |
| Policy instance | 2 |
| Insurance contract or identification number | 895168G | | Number of Individuals Covered | 588 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $24,323 | | Total amount of fees paid to insurance company | USD $8,126 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY PRODUCTS | | 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 $308,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 73547-7 |
| Policy instance | 1 |
| Insurance contract or identification number | 73547-7 | | Number of Individuals Covered | 723 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $38,890 | | Total amount of fees paid to insurance company | USD $4,744 | | 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 $948,796 | | 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 | 12130644 |
| Policy instance | 3 |
| Insurance contract or identification number | 12130644 | | Number of Individuals Covered | 428 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12130644 |
| Policy instance | 3 |
| Insurance contract or identification number | 12130644 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 948998 |
| Policy instance | 1 |
| Insurance contract or identification number | 948998 | | Number of Individuals Covered | 466 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $30,058 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,636,963 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 895168G |
| Policy instance | 2 |
| Insurance contract or identification number | 895168G | | Number of Individuals Covered | 632 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $12,439 | | Total amount of fees paid to insurance company | USD $15,624 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY PRODUCTS | | 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 $232,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-015188 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12130644 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 606066 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 606068 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12130644 |
| Policy instance | 4 |
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70956-5 |
| Policy instance | 1 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 606066 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 606068 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 606066 |
| Policy instance | 2 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB102204 |
| Policy instance | 1 |
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 69286-7 |
| Policy instance | 1 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB102204 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 404061 |
| Policy instance | 4 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 404060 |
| Policy instance | 3 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0755812 |
| Policy instance | 2 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 1 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 404060 |
| Policy instance | 3 |
| JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 ) |
| Policy contract number | 30505 |
| Policy instance | 2 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 1 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 404061 |
| Policy instance | 4 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 1 |
| JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 ) |
| Policy contract number | 30505 |
| Policy instance | 3 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 40937 |
| Policy instance | 2 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 2 |
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 504387 |
| Policy instance | 1 |
| JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 ) |
| Policy contract number | 30505 |
| Policy instance | 5 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 40937 |
| Policy instance | 4 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 504387 |
| Policy instance | 3 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 2 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 40937 |
| Policy instance | 5 |
| JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 ) |
| Policy contract number | 90063 |
| Policy instance | 3 |
| SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 ) |
| Policy contract number | D2415 |
| Policy instance | 6 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 504387 |
| Policy instance | 4 |
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 504387 |
| Policy instance | 1 |
| JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 ) |
| Policy contract number | 90063 |
| Policy instance | 3 |
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 504387 |
| Policy instance | 4 |
| SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 ) |
| Policy contract number | D2415 |
| Policy instance | 6 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 40937 |
| Policy instance | 5 |
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 504387 |
| Policy instance | 1 |
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 9818 |
| Policy instance | 2 |
