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LAROSA'S LIFE INSURANCE PLAN 401k Plan overview

Plan NameLAROSA'S LIFE INSURANCE PLAN
Plan identification number 502

LAROSA'S LIFE INSURANCE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

LAROSA'S, INC. has sponsored the creation of one or more 401k plans.

Company Name:LAROSA'S, INC.
Employer identification number (EIN):310711332
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Additional information about LAROSA'S, INC.

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division
Incorporation Date: 1965-05-21
Company Identification Number: 340517
Legal Registered Office Address: 300 AMERICAN BLDG
-
CINCINNATI
United States of America (USA)
45202

More information about LAROSA'S, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LAROSA'S LIFE INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-08-01SHAUNA DUVALL2023-10-27
5022021-08-01SHAUNA DUVALL2022-10-28
5022020-08-01SHAUNA DUVALL2021-12-22
5022019-08-01SHAUNA DUVALL2020-12-14
5022018-08-01SHAUNA DUVALL2020-02-10
5022017-08-01
5022016-08-01
5022015-08-01STEVE BROWNE, EXC. DIRECTOR OF HR
5022014-08-01STEVE BROWNE, EXEC. DIRECTOR OF HR
5022013-08-01STEVE BROWNE, EXEC DIRECTOR OF H.R.
5022012-08-01STEVE BROWNE, EXEC DIRECTOR OF H.R.
5022011-08-01STEVE BROWNE, EXEC DIRECTOR OF H.R.
5022010-08-01STEVE BROWNE, EXEC DIRECTOR OF H.R.
5022009-08-01STEVE BROWNE, EXEC DIRECTOR OF H.R.

Plan Statistics for LAROSA'S LIFE INSURANCE PLAN

401k plan membership statisitcs for LAROSA'S LIFE INSURANCE PLAN

Measure Date Value
2022: LAROSA'S LIFE INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-08-01285
Total number of active participants reported on line 7a of the Form 55002022-08-01217
Number of retired or separated participants receiving benefits2022-08-010
Number of other retired or separated participants entitled to future benefits2022-08-010
Total of all active and inactive participants2022-08-01217
Number of employers contributing to the scheme2022-08-010
2021: LAROSA'S LIFE INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-08-01289
Total number of active participants reported on line 7a of the Form 55002021-08-01285
Number of retired or separated participants receiving benefits2021-08-010
Number of other retired or separated participants entitled to future benefits2021-08-010
Total of all active and inactive participants2021-08-01285
Number of employers contributing to the scheme2021-08-010
2020: LAROSA'S LIFE INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01278
Total number of active participants reported on line 7a of the Form 55002020-08-01289
Number of retired or separated participants receiving benefits2020-08-010
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01289
Number of employers contributing to the scheme2020-08-010
2019: LAROSA'S LIFE INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01273
Total number of active participants reported on line 7a of the Form 55002019-08-01278
Number of retired or separated participants receiving benefits2019-08-010
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01278
Number of employers contributing to the scheme2019-08-010
2018: LAROSA'S LIFE INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01261
Total number of active participants reported on line 7a of the Form 55002018-08-01273
Number of retired or separated participants receiving benefits2018-08-010
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01273
Number of employers contributing to the scheme2018-08-010
2017: LAROSA'S LIFE INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01258
Total number of active participants reported on line 7a of the Form 55002017-08-01261
Number of retired or separated participants receiving benefits2017-08-010
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01261
Number of employers contributing to the scheme2017-08-010
2016: LAROSA'S LIFE INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01246
Total number of active participants reported on line 7a of the Form 55002016-08-01516
Number of retired or separated participants receiving benefits2016-08-010
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01516
2015: LAROSA'S LIFE INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01224
Total number of active participants reported on line 7a of the Form 55002015-08-01246
Total of all active and inactive participants2015-08-01246
2014: LAROSA'S LIFE INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01181
Total number of active participants reported on line 7a of the Form 55002014-08-01224
Total of all active and inactive participants2014-08-01224
2013: LAROSA'S LIFE INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01164
Total number of active participants reported on line 7a of the Form 55002013-08-01181
Total of all active and inactive participants2013-08-01181
2012: LAROSA'S LIFE INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01156
Total number of active participants reported on line 7a of the Form 55002012-08-01164
Total of all active and inactive participants2012-08-01164
2011: LAROSA'S LIFE INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year2011-08-01155
Total number of active participants reported on line 7a of the Form 55002011-08-01156
Total of all active and inactive participants2011-08-01156
2010: LAROSA'S LIFE INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year2010-08-01165
Total number of active participants reported on line 7a of the Form 55002010-08-01155
Total of all active and inactive participants2010-08-01155
2009: LAROSA'S LIFE INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year2009-08-01173
Total number of active participants reported on line 7a of the Form 55002009-08-01165
Number of retired or separated participants receiving benefits2009-08-010
Number of other retired or separated participants entitled to future benefits2009-08-010
Total of all active and inactive participants2009-08-01165
Total participants2009-08-01165

Form 5500 Responses for LAROSA'S LIFE INSURANCE PLAN

2022: LAROSA'S LIFE INSURANCE PLAN 2022 form 5500 responses
2022-08-01Type of plan entitySingle employer plan
2022-08-01Plan funding arrangement – InsuranceYes
2022-08-01Plan benefit arrangement – InsuranceYes
2021: LAROSA'S LIFE INSURANCE PLAN 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Plan funding arrangement – InsuranceYes
2021-08-01Plan benefit arrangement – InsuranceYes
2020: LAROSA'S LIFE INSURANCE PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: LAROSA'S LIFE INSURANCE PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: LAROSA'S LIFE INSURANCE PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: LAROSA'S LIFE INSURANCE PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – InsuranceYes
2016: LAROSA'S LIFE INSURANCE PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – InsuranceYes
2015: LAROSA'S LIFE INSURANCE PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Submission has been amendedNo
2015-08-01This submission is the final filingNo
2015-08-01This return/report is a short plan year return/report (less than 12 months)No
2015-08-01Plan is a collectively bargained planNo
2015-08-01Plan funding arrangement – InsuranceYes
2015-08-01Plan benefit arrangement – InsuranceYes
2014: LAROSA'S LIFE INSURANCE PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Submission has been amendedNo
2014-08-01This submission is the final filingNo
2014-08-01This return/report is a short plan year return/report (less than 12 months)No
2014-08-01Plan is a collectively bargained planNo
2014-08-01Plan funding arrangement – InsuranceYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: LAROSA'S LIFE INSURANCE PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Submission has been amendedNo
2013-08-01This submission is the final filingNo
2013-08-01This return/report is a short plan year return/report (less than 12 months)No
2013-08-01Plan is a collectively bargained planNo
2013-08-01Plan funding arrangement – InsuranceYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: LAROSA'S LIFE INSURANCE PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Submission has been amendedNo
2012-08-01This submission is the final filingNo
2012-08-01This return/report is a short plan year return/report (less than 12 months)No
2012-08-01Plan is a collectively bargained planNo
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – InsuranceYes
2011: LAROSA'S LIFE INSURANCE PLAN 2011 form 5500 responses
2011-08-01Type of plan entitySingle employer plan
2011-08-01Submission has been amendedNo
2011-08-01This submission is the final filingNo
2011-08-01This return/report is a short plan year return/report (less than 12 months)No
2011-08-01Plan is a collectively bargained planNo
2011-08-01Plan funding arrangement – InsuranceYes
2011-08-01Plan benefit arrangement – InsuranceYes
2010: LAROSA'S LIFE INSURANCE PLAN 2010 form 5500 responses
2010-08-01Type of plan entitySingle employer plan
2010-08-01Submission has been amendedNo
2010-08-01This submission is the final filingNo
2010-08-01This return/report is a short plan year return/report (less than 12 months)No
2010-08-01Plan is a collectively bargained planNo
2010-08-01Plan funding arrangement – InsuranceYes
2010-08-01Plan benefit arrangement – InsuranceYes
2009: LAROSA'S LIFE INSURANCE PLAN 2009 form 5500 responses
2009-08-01Type of plan entitySingle employer plan
2009-08-01Submission has been amendedNo
2009-08-01This submission is the final filingNo
2009-08-01This return/report is a short plan year return/report (less than 12 months)No
2009-08-01Plan is a collectively bargained planNo
2009-08-01Plan funding arrangement – InsuranceYes
2009-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10268076
Policy instance 1
Insurance contract or identification number10268076
Number of Individuals Covered217
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $16,753
Total amount of fees paid to insurance companyUSD $5,458
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 providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $111,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,753
Amount paid for insurance broker fees5458
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00006043
Policy instance 1
Insurance contract or identification numberAL00006043
Number of Individuals Covered285
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $8,664
Total amount of fees paid to insurance companyUSD $945
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $95,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,664
Amount paid for insurance broker fees945
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00006043
Policy instance 1
Insurance contract or identification numberAL00006043
Number of Individuals Covered289
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,577
Total amount of fees paid to insurance companyUSD $956
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $86,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,577
Amount paid for insurance broker fees956
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00006043
Policy instance 1
Insurance contract or identification numberAL00006043
Number of Individuals Covered278
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,793
Total amount of fees paid to insurance companyUSD $2,240
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $95,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,793
Amount paid for insurance broker fees2240
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00006043
Policy instance 1
Insurance contract or identification numberAL00006043
Number of Individuals Covered273
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,240
Total amount of fees paid to insurance companyUSD $3,924
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $94,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,657
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00006043
Policy instance 1
Insurance contract or identification numberAL00006043
Number of Individuals Covered261
Insurance policy start date2017-08-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,059
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $38,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,059
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number010157925
Policy instance 1
Insurance contract or identification number010157925
Number of Individuals Covered246
Insurance policy start date2015-08-01
Insurance policy end date2016-07-31
Total amount of commissions paid to insurance brokerUSD $9,467
Total amount of fees paid to insurance companyUSD $3,845
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $63,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,918
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameUSI MIDWEST INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number010157925
Policy instance 1
Insurance contract or identification number010157925
Number of Individuals Covered224
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $7,990
Total amount of fees paid to insurance companyUSD $3,044
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $53,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,990
Amount paid for insurance broker fees3044
Additional information about fees paid to insurance brokerFEES AND BROKER BONUS
Insurance broker organization code?3
Insurance broker nameUSI MIDWEST INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10157925
Policy instance 1
Insurance contract or identification number10157925
Number of Individuals Covered181
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $5,261
Total amount of fees paid to insurance companyUSD $1,867
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $35,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,261
Amount paid for insurance broker fees1867
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameUSI MIDWEST INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10157925
Policy instance 1
Insurance contract or identification number10157925
Number of Individuals Covered164
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $4,960
Total amount of fees paid to insurance companyUSD $195
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $33,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,960
Amount paid for insurance broker fees195
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameUSI MIDWEST INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10157925
Policy instance 1
Insurance contract or identification number10157925
Number of Individuals Covered156
Insurance policy start date2012-04-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $2,035
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
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 $13,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number1469861
Policy instance 2
Insurance contract or identification number1469861
Number of Individuals Covered153
Insurance policy start date2011-08-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $1,984
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number1469861
Policy instance 1
Insurance contract or identification number1469861
Number of Individuals Covered155
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $2,435
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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

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