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KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 401k Plan overview

Plan NameKEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN
Plan identification number 501

KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS 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)

401k Sponsoring company profile

KEFFER AUTOMOTIVE GROUP has sponsored the creation of one or more 401k plans.

Company Name:KEFFER AUTOMOTIVE GROUP
Employer identification number (EIN):331193599
NAIC Classification:441110
NAIC Description:New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01BRENDA JOHNSON2023-11-27
5012021-06-01BRENDA JOHNSON2022-10-20
5012020-06-01BRENDA JOHNSON2021-10-20
5012019-06-01BRENDA L. JOHNSON2020-09-23
5012018-06-01WENDY SANDERS2019-10-17
5012017-06-01WENDY SANDERS
5012017-06-01WENDY SANDERS2019-10-22
5012016-06-01WENDY SANDERS
5012015-06-01WENDY SANDERS
5012014-06-01WENDY SANDERS
5012013-06-01WENDY SANDERS

Plan Statistics for KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN

401k plan membership statisitcs for KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN

Measure Date Value
2022: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-01541
Total number of active participants reported on line 7a of the Form 55002022-06-01548
Number of retired or separated participants receiving benefits2022-06-014
Number of other retired or separated participants entitled to future benefits2022-06-0165
Total of all active and inactive participants2022-06-01617
Number of employers contributing to the scheme2022-06-010
2021: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01526
Total number of active participants reported on line 7a of the Form 55002021-06-01742
Number of retired or separated participants receiving benefits2021-06-018
Number of other retired or separated participants entitled to future benefits2021-06-0135
Total of all active and inactive participants2021-06-01785
Number of employers contributing to the scheme2021-06-010
2020: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01526
Total number of active participants reported on line 7a of the Form 55002020-06-01521
Number of retired or separated participants receiving benefits2020-06-010
Number of other retired or separated participants entitled to future benefits2020-06-0117
Total of all active and inactive participants2020-06-01538
Number of employers contributing to the scheme2020-06-010
2019: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01447
Total number of active participants reported on line 7a of the Form 55002019-06-01387
Number of retired or separated participants receiving benefits2019-06-019
Number of other retired or separated participants entitled to future benefits2019-06-0152
Total of all active and inactive participants2019-06-01448
Number of employers contributing to the scheme2019-06-010
2018: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01203
Total number of active participants reported on line 7a of the Form 55002018-06-01181
Number of retired or separated participants receiving benefits2018-06-011
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01182
Number of employers contributing to the scheme2018-06-010
2017: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01215
Total number of active participants reported on line 7a of the Form 55002017-06-01200
Number of retired or separated participants receiving benefits2017-06-013
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01203
Number of employers contributing to the scheme2017-06-010
2016: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01133
Total number of active participants reported on line 7a of the Form 55002016-06-01192
Number of retired or separated participants receiving benefits2016-06-012
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-01194
2015: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01144
Total number of active participants reported on line 7a of the Form 55002015-06-01162
Number of retired or separated participants receiving benefits2015-06-010
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01162
2014: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01130
Total number of active participants reported on line 7a of the Form 55002014-06-01144
Number of retired or separated participants receiving benefits2014-06-010
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-01144
2013: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01130
Total number of active participants reported on line 7a of the Form 55002013-06-01130
Number of retired or separated participants receiving benefits2013-06-010
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01130

Form 5500 Responses for KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN

2022: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – InsuranceYes
2021: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – InsuranceYes
2020: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – InsuranceYes
2019: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – InsuranceYes
2018: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – InsuranceYes
2017: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2016: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – General assets of the sponsorYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – General assets of the sponsorYes
2015: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes
2014: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan funding arrangement – General assets of the sponsorYes
2014-06-01Plan benefit arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – General assets of the sponsorYes
2013: KEFFER AUTOMOTIVE GROUP WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01First time form 5500 has been submittedYes
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan funding arrangement – General assets of the sponsorYes
2013-06-01Plan benefit arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number714179
Policy instance 4
Insurance contract or identification number714179
Number of Individuals Covered491
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $53,555
Total amount of fees paid to insurance companyUSD $26,520
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 $316,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,709
Amount paid for insurance broker fees15846
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number714182
Policy instance 3
Insurance contract or identification number714182
Number of Individuals Covered197
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $5,791
Total amount of fees paid to insurance companyUSD $1,235
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $39,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,827
Amount paid for insurance broker fees1235
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10229131001
Policy instance 2
Insurance contract or identification number10229131001
Number of Individuals Covered474
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $4,842
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $40,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,842
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161459-1001
Policy instance 1
Insurance contract or identification number14161459-1001
Number of Individuals Covered562
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $65,588
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedWELLNESS
Welfare Benefit Premiums Paid to CarrierUSD $3,023,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,588
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number887969G
Policy instance 3
Insurance contract or identification number887969G
Number of Individuals Covered486
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $32,164
Total amount of fees paid to insurance companyUSD $18,824
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 $268,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,164
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161459-1001
Policy instance 1
Insurance contract or identification number14161459-1001
Number of Individuals Covered592
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $38,725
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedWELLNESS
Welfare Benefit Premiums Paid to CarrierUSD $2,781,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,725
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 number10229131001
Policy instance 2
Insurance contract or identification number10229131001
Number of Individuals Covered442
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $4,900
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $37,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,900
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161459-1001
Policy instance 1
Insurance contract or identification number14161459-1001
Number of Individuals Covered570
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $64,090
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedWELLNESS
Welfare Benefit Premiums Paid to CarrierUSD $2,644,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $64,090
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number887969G
Policy instance 3
Insurance contract or identification number887969G
Number of Individuals Covered446
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $28,934
Total amount of fees paid to insurance companyUSD $16,861
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 $256,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,934
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 number10229131001
Policy instance 2
Insurance contract or identification number10229131001
Number of Individuals Covered425
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $3,959
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,959
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number887969G
Policy instance 3
Insurance contract or identification number887969G
Number of Individuals Covered480
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $34,035
Total amount of fees paid to insurance companyUSD $39,148
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 $237,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,035
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10229131001
Policy instance 2
Insurance contract or identification number10229131001
Number of Individuals Covered378
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,049
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,049
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number076228
Policy instance 1
Insurance contract or identification number076228
Number of Individuals Covered518
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $65,238
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,527,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,238
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 number10003201001
Policy instance 2
Insurance contract or identification number10003201001
Number of Individuals Covered196
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $410
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $335
Amount paid for insurance broker fees0
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD125189
Policy instance 4
Insurance contract or identification numberLTD125189
Number of Individuals Covered74
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $4,326
Total amount of fees paid to insurance companyUSD $1,531
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
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 $33,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,424
Amount paid for insurance broker fees1531
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES, FEES
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1053758
Policy instance 3
Insurance contract or identification number1053758
Number of Individuals Covered259
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $8,210
Total amount of fees paid to insurance companyUSD $4,374
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $99,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,506
Amount paid for insurance broker fees4374
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number076228
Policy instance 1
Insurance contract or identification number076228
Number of Individuals Covered208
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $49,869
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,145,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,869
Amount paid for insurance broker fees0
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD125189
Policy instance 4
Insurance contract or identification numberLTD125189
Number of Individuals Covered106
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $4,864
Total amount of fees paid to insurance companyUSD $51
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
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 $40,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1053758
Policy instance 3
Insurance contract or identification number1053758
Number of Individuals Covered283
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $7,240
Total amount of fees paid to insurance companyUSD $4,772
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $99,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10003201001
Policy instance 2
Insurance contract or identification number10003201001
Number of Individuals Covered172
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,743
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10003201001
Policy instance 5
Insurance contract or identification number10003201001
Number of Individuals Covered172
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,743
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 $16,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,743
Insurance broker organization code?3
Insurance broker nameDIGITAL BENEFIT ADVISORS
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 163516
Policy instance 4
Insurance contract or identification numberG 163516
Number of Individuals Covered80
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,252
Total amount of fees paid to insurance companyUSD $35
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 BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $22,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,252
Amount paid for insurance broker fees35
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 125189
Policy instance 3
Insurance contract or identification numberLTD 125189
Number of Individuals Covered106
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,612
Total amount of fees paid to insurance companyUSD $16
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $18,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,612
Amount paid for insurance broker fees16
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1053758
Policy instance 2
Insurance contract or identification number1053758
Number of Individuals Covered283
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $7,240
Total amount of fees paid to insurance companyUSD $4,772
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 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 $99,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,240
Amount paid for insurance broker fees4772
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameDIGITAL INSURANCE INC
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number076228
Policy instance 1
Insurance contract or identification number076228
Number of Individuals Covered206
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $52,311
Total amount of fees paid to insurance companyUSD $500
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,311
Amount paid for insurance broker fees500
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Welfare Benefit Premiums Paid to CarrierUSD $1,005,828
Insurance broker nameSHELLEY L MCLEAN

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