DOVER CHEMICAL CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN
401k plan membership statisitcs for DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 252 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 247 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 247 |
| 2021: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 251 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 254 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
| Total of all active and inactive participants | 2021-06-01 | 254 |
| 2020: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 230 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
| Total of all active and inactive participants | 2020-06-01 | 230 |
| 2019: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 231 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
| Total of all active and inactive participants | 2019-06-01 | 238 |
| 2018: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 246 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 246 |
| 2017: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 247 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 245 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 245 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-06-01 | 0 |
| Total participants | 2017-06-01 | 245 |
| 2016: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 245 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
| Total of all active and inactive participants | 2016-06-01 | 245 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-06-01 | 0 |
| Total participants | 2016-06-01 | 245 |
| 2015: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 241 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 243 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-06-01 | 0 |
| Total participants | 2015-06-01 | 243 |
| 2014: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 238 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 239 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 2 |
| Total of all active and inactive participants | 2014-06-01 | 241 |
| Total participants | 2014-06-01 | 241 |
| 2013: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 237 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 238 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-06-01 | 0 |
| Total participants | 2013-06-01 | 238 |
| 2012: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 243 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 237 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
| Total of all active and inactive participants | 2012-06-01 | 239 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-06-01 | 0 |
| Total participants | 2012-06-01 | 239 |
| 2011: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 242 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 1 |
| Total of all active and inactive participants | 2011-06-01 | 243 |
| 2010: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-06-01 | 231 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 233 |
| Total of all active and inactive participants | 2010-06-01 | 233 |
| 2009: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-06-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 231 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 0 |
| Total of all active and inactive participants | 2009-06-01 | 231 |
| 2022: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan is a collectively bargained plan | Yes |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan is a collectively bargained plan | Yes |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan is a collectively bargained plan | Yes |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan is a collectively bargained plan | Yes |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Plan is a collectively bargained plan | Yes |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | Plan is a collectively bargained plan | Yes |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Plan is a collectively bargained plan | Yes |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Plan is a collectively bargained plan | Yes |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Plan is a collectively bargained plan | Yes |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Plan is a collectively bargained plan | Yes |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Plan is a collectively bargained plan | Yes |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | Plan is a collectively bargained plan | Yes |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-06-01 | Type of plan entity | Single employer plan |
| 2010-06-01 | Plan funding arrangement – Insurance | Yes |
| 2010-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: DOVER CHEMICAL CORPORATION EMPLOYEES HEALTH BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-06-01 | Type of plan entity | Single employer plan |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | MP0B9S7 |
| Policy instance | 6 |
| Insurance contract or identification number | MP0B9S7 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMAD0B9S7 |
| Policy instance | 5 |
| Insurance contract or identification number | GMAD0B9S7 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMG0B9S7 |
| Policy instance | 4 |
| Insurance contract or identification number | GMG0B9S7 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMTD0B9S7 |
| Policy instance | 3 |
| Insurance contract or identification number | GMTD0B9S7 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,133 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GLCL0B9S7 |
| Policy instance | 2 |
| Insurance contract or identification number | GLCL0B9S7 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GCEL0B9S7 |
| Policy instance | 1 |
| Insurance contract or identification number | GCEL0B9S7 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GCEL0B9S7 |
| Policy instance | 1 |
| Insurance contract or identification number | GCEL0B9S7 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GLCL0B9S7 |
| Policy instance | 2 |
| Insurance contract or identification number | GLCL0B9S7 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMTD0B9S7 |
| Policy instance | 3 |
| Insurance contract or identification number | GMTD0B9S7 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,338 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMG0B9S7 |
| Policy instance | 4 |
| Insurance contract or identification number | GMG0B9S7 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $109,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMAD0B9S7 |
| Policy instance | 5 |
| Insurance contract or identification number | GMAD0B9S7 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $2,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | MP0B9S7 |
| Policy instance | 6 |
| Insurance contract or identification number | MP0B9S7 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GCEL0B9S7 |
| Policy instance | 1 |
| Insurance contract or identification number | GCEL0B9S7 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GLCL0B9S7 |
| Policy instance | 2 |
| Insurance contract or identification number | GLCL0B9S7 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMTD0B9S7 |
| Policy instance | 3 |
| Insurance contract or identification number | GMTD0B9S7 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMG0B9S7 |
| Policy instance | 4 |
| Insurance contract or identification number | GMG0B9S7 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMAD0B9S7 |
| Policy instance | 5 |
| Insurance contract or identification number | GMAD0B9S7 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $2,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | MP0B9S7 |
| Policy instance | 6 |
| Insurance contract or identification number | MP0B9S7 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | MP0B9S7 |
| Policy instance | 6 |
| Insurance contract or identification number | MP0B9S7 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMAD0B9S7 |
| Policy instance | 5 |
| Insurance contract or identification number | GMAD0B9S7 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Other welfare benefits provided | AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $2,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMG0B9S7 |
| Policy instance | 4 |
| Insurance contract or identification number | GMG0B9S7 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMTD0B9S7 |
| Policy instance | 3 |
| Insurance contract or identification number | GMTD0B9S7 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GLCL0B9S7 |
| Policy instance | 2 |
| Insurance contract or identification number | GLCL0B9S7 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | GCEL0B9S7 |
| Policy instance | 1 |
| Insurance contract or identification number | GCEL0B9S7 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 1 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,424 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $91,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,424 | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 1 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 532 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,081 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $87,166 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,081 | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,646 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of fees paid to insurance company | USD $1,114 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,229 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1114 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 1 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 545 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $5,375 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD+D | | Welfare Benefit Premiums Paid to Carrier | USD $86,383 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,375 | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of fees paid to insurance company | USD $1,249 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1249 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 2 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 522 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,950 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $90,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,950 | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
| Policy contract number | 12218941 |
| Policy instance | 1 |
| Insurance contract or identification number | 12218941 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-01-01 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,456 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,634 | | 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: 47029 ) |
| Policy contract number | 12218941 |
| Policy instance | 5 |
| Insurance contract or identification number | 12218941 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,205 | | 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: 47029 ) |
| Policy contract number | 12218941 |
| Policy instance | 1 |
| Insurance contract or identification number | 12218941 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 2 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 697 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,586 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,586 | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of fees paid to insurance company | USD $8,530 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 8530 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of fees paid to insurance company | USD $9,046 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 9046 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT G. HILLOWE |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135760000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010135760000 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,579 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0075 |
| Policy instance | 2 |
| Insurance contract or identification number | NY0075 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,840 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,912 | | 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: 47029 ) |
| Policy contract number | 12218941 |
| Policy instance | 1 |
| Insurance contract or identification number | 12218941 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,338 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010135761000 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010135761000 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,151 | | 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: 47029 ) |
| Policy contract number | 12218941 |
| Policy instance | 1 |
| Insurance contract or identification number | 12218941 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2010-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 63825-1 |
| Policy instance | 2 |
| Insurance contract or identification number | 63825-1 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $242,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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