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CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameCARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN
Plan identification number 501

CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CARPET WEAVERS, INC. has sponsored the creation of one or more 401k plans.

Company Name:CARPET WEAVERS, INC.
Employer identification number (EIN):371238997
NAIC Classification:442210
NAIC Description:Floor Covering Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01FRANK HOSEK
5012017-01-01FRANK HOSEK
5012016-01-01FRANK HOSEK
5012011-01-01FRANK HOSEK FRANK HOSEK2015-11-24
5012009-01-01SCOTT BROWN

Plan Statistics for CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01106
Total number of active participants reported on line 7a of the Form 55002022-01-01100
Number of retired or separated participants receiving benefits2022-01-011
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01101
2021: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-0197
Total number of active participants reported on line 7a of the Form 55002021-01-0197
Number of retired or separated participants receiving benefits2021-01-011
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-0198
2020: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01116
Total number of active participants reported on line 7a of the Form 55002020-01-01102
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 participants2020-01-01102
2019: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01108
Total number of active participants reported on line 7a of the Form 55002019-01-01108
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 participants2019-01-01108
2018: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01115
Total number of active participants reported on line 7a of the Form 55002018-01-01107
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 participants2018-01-01107
2017: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01111
Total number of active participants reported on line 7a of the Form 55002017-01-01114
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 participants2017-01-01114
2016: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01112
Total number of active participants reported on line 7a of the Form 55002016-01-01110
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 participants2016-01-01110
2011: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01167
Total number of active participants reported on line 7a of the Form 55002011-01-0162
Number of retired or separated participants receiving benefits2011-01-017
Total of all active and inactive participants2011-01-0169
2009: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01144
Total number of active participants reported on line 7a of the Form 55002009-01-01153
Number of retired or separated participants receiving benefits2009-01-017
Total of all active and inactive participants2009-01-01160

Form 5500 Responses for CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN

2022: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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: CARPET WEAVERS, INC. EMPLOYEE BENEFITS 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
2011: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedYes
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: CARPET WEAVERS, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )
Policy contract number0800000523
Policy instance 4
Insurance contract or identification number0800000523
Number of Individuals Covered12
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $133
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedOFF THE JOB ACCIDENT EXPENSE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered35
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $14,029
Total amount of fees paid to insurance companyUSD $333
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $308,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,029
Amount paid for insurance broker fees333
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered100
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,006
Total amount of fees paid to insurance companyUSD $2,669
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $40,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,006
Amount paid for insurance broker fees2669
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05974683
Policy instance 1
Insurance contract or identification numberKM05974683
Number of Individuals Covered132
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,694
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,694
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered92
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,972
Total amount of fees paid to insurance companyUSD $2,817
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $39,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,972
Amount paid for insurance broker fees2817
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered42
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $15,009
Total amount of fees paid to insurance companyUSD $333
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $334,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,009
Amount paid for insurance broker fees333
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )
Policy contract number0800000523
Policy instance 4
Insurance contract or identification number0800000523
Number of Individuals Covered15
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $410
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedOFF THE JOB ACCIDENT EXPENSE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $255
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5974683
Policy instance 1
Insurance contract or identification number5974683
Number of Individuals Covered144
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,706
Total amount of fees paid to insurance companyUSD $14
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,706
Amount paid for insurance broker fees14
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )
Policy contract number0800000523
Policy instance 4
Insurance contract or identification number0800000523
Number of Individuals Covered24
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $2,554
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedOFF THE JOB ACCIDENT EXPENSE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,574
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered44
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $15,312
Total amount of fees paid to insurance companyUSD $342
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $345,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,312
Amount paid for insurance broker fees342
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered96
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,764
Total amount of fees paid to insurance companyUSD $3,090
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $38,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,764
Amount paid for insurance broker fees3090
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number776085
Policy instance 1
Insurance contract or identification number776085
Number of Individuals Covered58
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,338
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $33,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,338
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered44
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $14,297
Total amount of fees paid to insurance companyUSD $324
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $316,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,297
Amount paid for insurance broker fees324
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered112
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,387
Total amount of fees paid to insurance companyUSD $3,442
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT LIFE , DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $42,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,387
Amount paid for insurance broker fees3442
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number776085
Policy instance 1
Insurance contract or identification number776085
Number of Individuals Covered63
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,324
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $33,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,324
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number776085
Policy instance 1
Insurance contract or identification number776085
Number of Individuals Covered66
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,179
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,711
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,179
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered107
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,357
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT LIFE , DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $42,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,357
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered40
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $14,003
Total amount of fees paid to insurance companyUSD $351
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $313,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,003
Amount paid for insurance broker fees351
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP53838,P54105
Policy instance 3
Insurance contract or identification numberP53838,P54105
Number of Individuals Covered47
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $15,052
Total amount of fees paid to insurance companyUSD $306
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $334,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,052
Amount paid for insurance broker fees306
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameCLEMONS & ASSOCIATES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF014673
Policy instance 2
Insurance contract or identification numberF014673
Number of Individuals Covered117
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $9,722
Total amount of fees paid to insurance companyUSD $2,904
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL AD&D, DEPENDENT LIFE , DEPENDENT AD&D, SUPPLEMENTAL LIFE
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 $64,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,722
Amount paid for insurance broker fees2904
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameCLEMONS & ASSOCIATES LIFE AGENCY LT
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number776085
Policy instance 1
Insurance contract or identification number776085
Number of Individuals Covered67
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,164
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,164
Insurance broker organization code?3
Insurance broker nameCLEMENS & ASSOCIATES LIFE AGEN

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