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KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 401k Plan overview

Plan NameKOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN
Plan identification number 501

KOSEI ST. MARYS CORPORATION 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

KOSEI ST. MARYS CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:KOSEI ST. MARYS CORPORATION
Employer identification number (EIN):341564600
NAIC Classification:332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01DAN HOSEK2023-07-10
5012021-01-01DAN HOSEK2022-07-20
5012020-01-01DANIEL HOSEK2021-09-20
5012019-03-01

Plan Statistics for KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN

401k plan membership statisitcs for KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN

Measure Date Value
2022: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01499
Total number of active participants reported on line 7a of the Form 55002022-01-01396
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 participants2022-01-01396
Number of employers contributing to the scheme2022-01-010
2021: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01630
Total number of active participants reported on line 7a of the Form 55002021-01-01499
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 participants2021-01-01499
Number of employers contributing to the scheme2021-01-010
2020: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01553
Total number of active participants reported on line 7a of the Form 55002020-01-01630
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 participants2020-01-01630
Number of employers contributing to the scheme2020-01-010
2019: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01632
Total number of active participants reported on line 7a of the Form 55002019-03-01548
Number of retired or separated participants receiving benefits2019-03-015
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01553

Form 5500 Responses for KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN

2022: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: KOSEI ST. MARYS CORPORATION WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01First time form 5500 has been submittedYes
2019-03-01Submission has been amendedNo
2019-03-01This submission is the final filingNo
2019-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-03-01Plan is a collectively bargained planNo
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan funding arrangement – General assets of the sponsorYes
2019-03-01Plan benefit arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

GRAND LAKE HEALTH SYSTEMS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered865
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $9,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30089954
Policy instance 3
Insurance contract or identification number30089954
Number of Individuals Covered277
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 $44,024
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
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017987-00
Policy instance 2
Insurance contract or identification number01-017987-00
Number of Individuals Covered277
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $31,612
Total amount of fees paid to insurance companyUSD $12,084
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 $346,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,612
Amount paid for insurance broker fees11656
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker organization code?3
DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )
Policy contract number2458
Policy instance 1
Insurance contract or identification number2458
Number of Individuals Covered566
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $21,793
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 $21,793
Amount paid for insurance broker fees0
Insurance broker organization code?3
GRAND LAKE HEALTH SYSTEMS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered1145
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $12,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30089954
Policy instance 3
Insurance contract or identification number30089954
Number of Individuals Covered314
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,388
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,388
Amount paid for insurance broker fees0
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017987-00
Policy instance 2
Insurance contract or identification number01-017987-00
Number of Individuals Covered325
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $30,988
Total amount of fees paid to insurance companyUSD $3,596
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 $345,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,988
Amount paid for insurance broker fees3121
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker organization code?3
DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )
Policy contract number2458
Policy instance 1
Insurance contract or identification number2458
Number of Individuals Covered712
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $25,152
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 $25,152
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered1447
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $10,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30089954
Policy instance 3
Insurance contract or identification number30089954
Number of Individuals Covered412
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,356
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,356
Amount paid for insurance broker fees0
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017987-00
Policy instance 2
Insurance contract or identification number01-017987-00
Number of Individuals Covered423
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $57,196
Total amount of fees paid to insurance companyUSD $16,949
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 $636,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,196
Amount paid for insurance broker fees16949
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker organization code?3
DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )
Policy contract number2458
Policy instance 1
Insurance contract or identification number2458
Number of Individuals Covered986
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $38,896
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 $38,896
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30089954
Policy instance 4
Insurance contract or identification number30089954
Number of Individuals Covered487
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,897
Total amount of fees paid to insurance companyUSD $0
Vision 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 $6,897
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-017987-00
Policy instance 3
Insurance contract or identification number01-017987-00
Number of Individuals Covered514
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $9,316
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $362,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees9316
Additional information about fees paid to insurance brokerGROUP VOLUME BONUS
Insurance broker organization code?3
DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 )
Policy contract number0002458
Policy instance 2
Insurance contract or identification number0002458
Number of Individuals Covered1190
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $30,387
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 $30,387
Insurance broker organization code?3

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