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ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 401k Plan overview

Plan NameADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN
Plan identification number 501

ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Other welfare benefit cover

401k Sponsoring company profile

ADAMS COUNTY REGIONAL MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name:ADAMS COUNTY REGIONAL MEDICAL CENTER
Employer identification number (EIN):316402534
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01
5012021-02-01
5012020-02-01
5012019-10-01

Plan Statistics for ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN

401k plan membership statisitcs for ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN

Measure Date Value
2022: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01187
Total number of active participants reported on line 7a of the Form 55002022-02-01208
Number of retired or separated participants receiving benefits2022-02-010
Number of other retired or separated participants entitled to future benefits2022-02-010
Total of all active and inactive participants2022-02-01208
2021: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01207
Total number of active participants reported on line 7a of the Form 55002021-02-01187
Number of retired or separated participants receiving benefits2021-02-010
Number of other retired or separated participants entitled to future benefits2021-02-010
Total of all active and inactive participants2021-02-01187
2020: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-01115
Total number of active participants reported on line 7a of the Form 55002020-02-01207
Number of retired or separated participants receiving benefits2020-02-010
Number of other retired or separated participants entitled to future benefits2020-02-010
Total of all active and inactive participants2020-02-01207
2019: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-010
Total number of active participants reported on line 7a of the Form 55002019-10-01115
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01115

Form 5500 Responses for ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN

2022: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan funding arrangement – General assets of the sponsorYes
2022-02-01Plan benefit arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – General assets of the sponsorYes
2021: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Submission has been amendedNo
2021-02-01This submission is the final filingNo
2021-02-01This return/report is a short plan year return/report (less than 12 months)No
2021-02-01Plan is a collectively bargained planNo
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan funding arrangement – General assets of the sponsorYes
2021-02-01Plan benefit arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – General assets of the sponsorYes
2020: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedNo
2020-02-01This submission is the final filingNo
2020-02-01This return/report is a short plan year return/report (less than 12 months)No
2020-02-01Plan is a collectively bargained planNo
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan funding arrangement – General assets of the sponsorYes
2020-02-01Plan benefit arrangement – InsuranceYes
2020-02-01Plan benefit arrangement – General assets of the sponsorYes
2019: ADAMS COUNTY REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01First time form 5500 has been submittedYes
2019-10-01Submission has been amendedNo
2019-10-01This submission is the final filingNo
2019-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-10-01Plan is a collectively bargained planNo
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number924924
Policy instance 4
Insurance contract or identification number924924
Number of Individuals Covered90
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $7,600
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 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 $41,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,600
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30046434
Policy instance 3
Insurance contract or identification number30046434
Number of Individuals Covered107
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $981
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 $15,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $981
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberDD1062
Policy instance 2
Insurance contract or identification numberDD1062
Number of Individuals Covered131
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $4,333
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $74,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,333
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number00172081
Policy instance 1
Insurance contract or identification number00172081
Number of Individuals Covered208
Insurance policy start date2022-02-01
Insurance policy end date2023-01-30
Total amount of commissions paid to insurance brokerUSD $293
Total amount of fees paid to insurance companyUSD $146
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOLUNTARY LIFE & AD&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 $3,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $293
Insurance broker organization code?3
Amount paid for insurance broker fees146
Additional information about fees paid to insurance brokerOTHER COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30046434
Policy instance 3
Insurance contract or identification number30046434
Number of Individuals Covered89
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $875
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 $12,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $875
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberDD1062
Policy instance 2
Insurance contract or identification numberDD1062
Number of Individuals Covered118
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $7,321
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $79,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,039
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number00172081
Policy instance 1
Insurance contract or identification number00172081
Number of Individuals Covered187
Insurance policy start date2021-02-01
Insurance policy end date2022-01-30
Total amount of commissions paid to insurance brokerUSD $121
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOLUNTARY LIFE & AD&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 $1,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $213
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number924924
Policy instance 4
Insurance contract or identification number924924
Number of Individuals Covered91
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $6,113
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 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 $30,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,113
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number924924
Policy instance 4
Insurance contract or identification number924924
Number of Individuals Covered91
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $14,201
Total amount of fees paid to insurance companyUSD $2,764
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 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 $32,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,201
Insurance broker organization code?3
Amount paid for insurance broker fees2764
Additional information about fees paid to insurance brokerADDITIONAL PAYMENTS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30046434
Policy instance 3
Insurance contract or identification number30046434
Number of Individuals Covered89
Insurance policy start date2020-10-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $875
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 $12,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $875
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberDD1062
Policy instance 2
Insurance contract or identification numberDD1062
Number of Individuals Covered117
Insurance policy start date2020-10-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $6,753
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $70,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,712
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number00172081
Policy instance 1
Insurance contract or identification number00172081
Number of Individuals Covered207
Insurance policy start date2020-10-01
Insurance policy end date2021-01-30
Total amount of commissions paid to insurance brokerUSD $217
Total amount of fees paid to insurance companyUSD $19
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOLUNTARY LIFE & AD&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 $2,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $217
Amount paid for insurance broker fees19
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30046434
Policy instance 3
Insurance contract or identification number30046434
Number of Individuals Covered92
Insurance policy start date2019-10-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $89
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 $4,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $89
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberDD1062
Policy instance 2
Insurance contract or identification numberDD1062
Number of Individuals Covered115
Insurance policy start date2019-10-01
Insurance policy end date2020-01-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number00172081
Policy instance 1
Insurance contract or identification number00172081
Number of Individuals Covered196
Insurance policy start date2019-10-01
Insurance policy end date2020-01-30
Total amount of commissions paid to insurance brokerUSD $79
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOLUNTARY LIFE & AD&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 $811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79
Insurance broker organization code?3

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