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CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 401k Plan overview

Plan NameCAVALIER DISTRIBUTING WELFARE BENEFIT PLAN
Plan identification number 501

CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

CAVALIER DISTRIBUTING COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name:CAVALIER DISTRIBUTING COMPANY, INC.
Employer identification number (EIN):311356420
NAIC Classification:424800

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01KYLE ALLEN2023-06-16
5012021-01-01KYLE ALLEN2022-03-10
5012020-01-01KYLE ALLEN2021-07-07
5012019-01-01KYLE ALLEN2020-06-22
5012018-01-01KYLE ALLEN2019-12-03
5012017-01-01
5012016-01-01

Plan Statistics for CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN

401k plan membership statisitcs for CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN

Measure Date Value
2022: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01207
Total number of active participants reported on line 7a of the Form 55002022-01-01307
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01307
Number of employers contributing to the scheme2022-01-010
2021: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01210
Total number of active participants reported on line 7a of the Form 55002021-01-01207
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01207
Number of employers contributing to the scheme2021-01-010
2020: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01198
Total number of active participants reported on line 7a of the Form 55002020-01-01210
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01210
Number of employers contributing to the scheme2020-01-010
2019: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01190
Total number of active participants reported on line 7a of the Form 55002019-01-01206
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01206
Number of employers contributing to the scheme2019-01-010
2018: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01281
Total number of active participants reported on line 7a of the Form 55002018-01-01295
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01295
Number of employers contributing to the scheme2018-01-010
2017: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01279
Total number of active participants reported on line 7a of the Form 55002017-01-01295
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01295
2016: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01180
Total number of active participants reported on line 7a of the Form 55002016-01-01284
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01284

Form 5500 Responses for CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN

2022: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: CAVALIER DISTRIBUTING WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan 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 number400253101
Policy instance 3
Insurance contract or identification number400253101
Number of Individuals Covered307
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $6,756
Total amount of fees paid to insurance companyUSD $1,909
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $49,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,756
Amount paid for insurance broker fees1909
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05969934
Policy instance 2
Insurance contract or identification numberTM05969934
Number of Individuals Covered406
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $3,689
Total amount of fees paid to insurance companyUSD $4,517
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,689
Amount paid for insurance broker fees4517
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION, PRODUCER SERVICE FEES, NON-MONETARY COMPENSATION
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberW43339
Policy instance 1
Insurance contract or identification numberW43339
Number of Individuals Covered315
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $51,280
Total amount of fees paid to insurance companyUSD $3,960
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $776,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,280
Amount paid for insurance broker fees3960
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400253101
Policy instance 3
Insurance contract or identification number400253101
Number of Individuals Covered291
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $6,860
Total amount of fees paid to insurance companyUSD $1,750
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $50,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,860
Amount paid for insurance broker fees1750
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5969934
Policy instance 2
Insurance contract or identification number5969934
Number of Individuals Covered431
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $4,220
Total amount of fees paid to insurance companyUSD $4,739
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $84,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,220
Amount paid for insurance broker fees4288
Additional information about fees paid to insurance brokerSERVICE FEES, NON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberW43339
Policy instance 1
Insurance contract or identification numberW43339
Number of Individuals Covered311
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $50,140
Total amount of fees paid to insurance companyUSD $202
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $856,510
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,140
Amount paid for insurance broker fees202
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 )
Policy contract number5279801
Policy instance 2
Insurance contract or identification number5279801
Number of Individuals Covered320
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $3,420
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,420
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400253101
Policy instance 3
Insurance contract or identification number400253101
Number of Individuals Covered317
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $6,791
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $47,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,791
Amount paid for insurance broker fees0
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number224622
Policy instance 1
Insurance contract or identification number224622
Number of Individuals Covered310
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $49,540
Total amount of fees paid to insurance companyUSD $2,445
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $741,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,640
Amount paid for insurance broker fees2490
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10216666
Policy instance 4
Insurance contract or identification number10216666
Number of Individuals Covered316
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $5,302
Total amount of fees paid to insurance companyUSD $0
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 $33,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,601
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99110901001
Policy instance 3
Insurance contract or identification number99110901001
Number of Individuals Covered224
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,545
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,413
Amount paid for insurance broker fees0
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number224622
Policy instance 1
Insurance contract or identification number224622
Number of Individuals Covered273
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $43,320
Total amount of fees paid to insurance companyUSD $14,220
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $871,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,320
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 )
Policy contract number5279801
Policy instance 2
Insurance contract or identification number5279801
Number of Individuals Covered295
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $5,820
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,713
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10216666
Policy instance 4
Insurance contract or identification number10216666
Number of Individuals Covered295
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,038
Total amount of fees paid to insurance companyUSD $0
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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,038
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99110901001
Policy instance 3
Insurance contract or identification number99110901001
Number of Individuals Covered184
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,423
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,423
Amount paid for insurance broker fees0
Insurance broker organization code?3
DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 )
Policy contract number5279801,5279201
Policy instance 2
Insurance contract or identification number5279801,5279201
Number of Individuals Covered246
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $5,607
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,607
Amount paid for insurance broker fees0
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number224622
Policy instance 1
Insurance contract or identification number224622
Number of Individuals Covered273
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $45,760
Total amount of fees paid to insurance companyUSD $940
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $875,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,760
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number99110901001
Policy instance 5
Insurance contract or identification number99110901001
Number of Individuals Covered192
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $1,206
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $626
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
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 number000010216667
Policy instance 4
Insurance contract or identification number000010216667
Number of Individuals Covered22
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $805
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
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 $5,364
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $453
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract number899592
Policy instance 3
Insurance contract or identification number899592
Number of Individuals Covered20
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $1,181
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY BENEFITS - AD&D AND STD
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 $10,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $647
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameCINCINNATI BENEFIT SOLUTIONS
DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 )
Policy contract number05279201
Policy instance 2
Insurance contract or identification number05279201
Number of Individuals Covered259
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $6,303
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,303
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameED SOMMER
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract number00224622
Policy instance 1
Insurance contract or identification number00224622
Number of Individuals Covered289
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $49,420
Total amount of fees paid to insurance companyUSD $571
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $963,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,780
Amount paid for insurance broker fees290
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameUSI MIDEWEST LLC

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