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CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 401k Plan overview

Plan NameCUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN
Plan identification number 508

CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CUMMINS INC. has sponsored the creation of one or more 401k plans.

Company Name:CUMMINS INC.
Employer identification number (EIN):350257090
NAIC Classification:333610

Additional information about CUMMINS INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 2004-12-08
Company Identification Number: 602452121
Legal Registered Office Address: 10000 NE 7TH AVE NE STE 130

VANCOUVER
United States of America (USA)
98685

More information about CUMMINS INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5082022-01-01
5082021-01-01
5082020-01-01
5082019-01-01
5082018-01-01
5082017-01-01DONALD JACKSON
5082016-01-01DONALD JACKSON
5082015-01-01DONALD JACKSON
5082014-01-01DONALD JACKSON DONALD JACKSON2015-07-28
5082013-01-01RICHARD HARRIS RICHARD HARRIS2014-09-09
5082012-01-01RICHARD HARRIS RICHARD HARRIS2013-07-18
5082011-01-01RICHARD HARRIS RICHARD HARRIS2012-07-20
5082010-01-01RICHARD HARRIS RICHARD HARRIS2011-07-22
5082009-01-01RICHARD HARRIS RICHARD HARRIS2010-10-05

Plan Statistics for CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN

401k plan membership statisitcs for CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN

Measure Date Value
2022: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-0128,915
Total number of active participants reported on line 7a of the Form 55002022-01-0130,515
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 participants2022-01-0130,515
2021: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-0127,772
Total number of active participants reported on line 7a of the Form 55002021-01-0127,872
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 participants2021-01-0127,872
2020: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-0130,514
Total number of active participants reported on line 7a of the Form 55002020-01-0127,767
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 participants2020-01-0127,767
2019: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-0131,548
Total number of active participants reported on line 7a of the Form 55002019-01-0131,007
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-0131,007
2018: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-0130,080
Total number of active participants reported on line 7a of the Form 55002018-01-0131,536
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-0131,536
2017: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-0123,566
Total number of active participants reported on line 7a of the Form 55002017-01-0129,246
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-0129,246
2016: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-0122,533
Total number of active participants reported on line 7a of the Form 55002016-01-0121,502
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-0121,502
2015: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-0118,466
Total number of active participants reported on line 7a of the Form 55002015-01-0120,483
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-0120,483
2014: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-0117,305
Total number of active participants reported on line 7a of the Form 55002014-01-0118,540
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-0118,540
2013: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-0117,163
Total number of active participants reported on line 7a of the Form 55002013-01-0117,323
Total of all active and inactive participants2013-01-0117,323
2012: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-0116,323
Total number of active participants reported on line 7a of the Form 55002012-01-0115,000
Total of all active and inactive participants2012-01-0115,000
2011: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-0115,183
Total number of active participants reported on line 7a of the Form 55002011-01-0113,177
Total of all active and inactive participants2011-01-0113,177
2010: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-0115,032
Total number of active participants reported on line 7a of the Form 55002010-01-0113,820
Number of retired or separated participants receiving benefits2010-01-010
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-0113,820
2009: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-0117,088
Total number of active participants reported on line 7a of the Form 55002009-01-0114,786
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-0114,786
Total participants2009-01-010

Form 5500 Responses for CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN

2022: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: CUMMINS GROUP TRAVEL ACCIDENT INSURANCE PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered30515
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $38,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered27872
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $38,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered27767
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $38,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered31007
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $53,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered29246
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered20483
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $12,381
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $85,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,381
Insurance broker organization code?3
Insurance broker nameAON
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered18540
Insurance policy start date2013-12-01
Insurance policy end date2014-12-01
Total amount of commissions paid to insurance brokerUSD $14,329
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $98,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,329
Insurance broker organization code?3
Insurance broker nameSANDY LAFERIERE
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered17323
Insurance policy start date2012-12-01
Insurance policy end date2013-12-01
Total amount of commissions paid to insurance brokerUSD $12,696
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $85,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,696
Insurance broker organization code?3
Insurance broker nameSANDY LAFERIERE
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered15000
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $53,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered13177
Insurance policy start date2010-12-01
Insurance policy end date2011-12-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $53,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N00326501
Policy instance 1
Insurance contract or identification numberADD N00326501
Number of Individuals Covered13820
Insurance policy start date2009-12-01
Insurance policy end date2010-12-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $53,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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