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POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 401k Plan overview

Plan NamePOLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN
Plan identification number 501

POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

POLACK PRINTING, INC. has sponsored the creation of one or more 401k plans.

Company Name:POLACK PRINTING, INC.
Employer identification number (EIN):381863547
NAIC Classification:511190

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01REBECCA WRIGHT2023-05-21
5012021-01-01REBECCA WRIGHT2022-07-26
5012011-10-01KEVIN STAPLETON KEVIN STAPLETON2013-07-13
5012010-10-01KEVIN STAPLETON KEVIN STAPLETON2013-07-13
5012009-10-01KEVIN STAPLETON
5012009-10-01KEVIN STAPLETON KEVIN STAPLETON2013-07-15
5012008-10-01KEVIN STAPLETON KEVIN STAPLETON2013-07-13

Plan Statistics for POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN

401k plan membership statisitcs for POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN

Measure Date Value
2022: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01127
Total number of active participants reported on line 7a of the Form 55002022-01-01151
Total of all active and inactive participants2022-01-01151
2021: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01160
Total number of active participants reported on line 7a of the Form 55002021-01-01141
Number of retired or separated participants receiving benefits2021-01-012
Total of all active and inactive participants2021-01-01143
2011: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01140
Total number of active participants reported on line 7a of the Form 55002011-10-01124
Total of all active and inactive participants2011-10-01124
2010: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-10-01135
Total number of active participants reported on line 7a of the Form 55002010-10-01140
Total of all active and inactive participants2010-10-01140
2009: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01120
Total number of active participants reported on line 7a of the Form 55002009-10-01120
Total of all active and inactive participants2009-10-01120
Total participants2009-10-01120
2008: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year2008-10-01133
Total number of active participants reported on line 7a of the Form 55002008-10-01138
Total of all active and inactive participants2008-10-01138

Financial Data on POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN

Measure Date Value
2012 : POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2012 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-09-30$283,695
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-09-30$297,428
Total income from all sources (including contributions)2012-09-30$2,539,306
Total of all expenses incurred2012-09-30$1,917,354
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2012-09-30$1,881,617
Total contributions o plan (from employers,participants, others, non cash contrinutions)2012-09-30$2,538,094
Value of total assets at end of year2012-09-30$1,005,371
Value of total assets at beginning of year2012-09-30$397,152
Total of administrative expenses incurred including professional, contract, advisory and management fees2012-09-30$35,737
Total interest from all sources2012-09-30$1,212
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-09-30No
Administrative expenses professional fees incurred2012-09-30$5,000
Was this plan covered by a fidelity bond2012-09-30Yes
Value of fidelity bond cover2012-09-30$500,000
If this is an individual account plan, was there a blackout period2012-09-30No
Were there any nonexempt tranactions with any party-in-interest2012-09-30No
Contributions received from participants2012-09-30$587,717
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-09-30No
Value of net income/loss2012-09-30$621,952
Value of net assets at end of year (total assets less liabilities)2012-09-30$721,676
Value of net assets at beginning of year (total assets less liabilities)2012-09-30$99,724
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2012-09-30No
Were any leases to which the plan was party in default or uncollectible2012-09-30No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2012-09-30$1,005,371
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2012-09-30$397,152
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2012-09-30$397,152
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2012-09-30$1,212
Expenses. Payments to insurance carriers foe the provision of benefits2012-09-30$732,751
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-09-30No
Was there a failure to transmit to the plan any participant contributions2012-09-30No
Has the plan failed to provide any benefit when due under the plan2012-09-30No
Contributions received in cash from employer2012-09-30$1,950,377
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2012-09-30$1,148,866
Contract administrator fees2012-09-30$30,737
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32012-09-30No
Liabilities. Value of benefit claims payable at end of year2012-09-30$283,695
Liabilities. Value of benefit claims payable at beginning of year2012-09-30$297,428
Did the plan have assets held for investment2012-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-09-30No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2012-09-30No
Opinion of an independent qualified public accountant for this plan2012-09-30Unqualified
Accountancy firm name2012-09-30MONROE SWEERIS & TROMP PLC
Accountancy firm EIN2012-09-30382621598
2011 : POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2011 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2011-09-30$297,428
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2011-09-30$321,064
Total income from all sources (including contributions)2011-09-30$1,910,859
Total of all expenses incurred2011-09-30$2,058,422
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2011-09-30$2,007,012
Total contributions o plan (from employers,participants, others, non cash contrinutions)2011-09-30$1,909,004
Value of total assets at end of year2011-09-30$397,152
Value of total assets at beginning of year2011-09-30$568,351
Total of administrative expenses incurred including professional, contract, advisory and management fees2011-09-30$51,410
Total interest from all sources2011-09-30$1,855
Total income from all sources2011-09-30$1,810,697
Expenses. Total of all expenses incurred2011-09-30$1,981,896
Benefits paid (including direct rollovers)2011-09-30$1,930,486
Total plan assets at end of year2011-09-30$397,152
Total plan assets at beginning of year2011-09-30$568,351
Expenses. Other expenses not covered elsewhere2011-09-30$51,410
Other income received2011-09-30$1,855
Net income (gross income less expenses)2011-09-30$-171,199
Net plan assets at end of year (total assets less liabilities)2011-09-30$397,152
Net plan assets at beginning of year (total assets less liabilities)2011-09-30$568,351
Total contributions received or receivable from employer(s)2011-09-30$1,808,842
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2011-09-30No
Administrative expenses professional fees incurred2011-09-30$8,000
Was this plan covered by a fidelity bond2011-09-30Yes
Value of fidelity bond cover2011-09-30$500,000
If this is an individual account plan, was there a blackout period2011-09-30No
Were there any nonexempt tranactions with any party-in-interest2011-09-30No
Contributions received from participants2011-09-30$545,720
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2011-09-30No
Value of net income/loss2011-09-30$-147,563
Value of net assets at end of year (total assets less liabilities)2011-09-30$99,724
Value of net assets at beginning of year (total assets less liabilities)2011-09-30$247,287
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2011-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2011-09-30No
Were any leases to which the plan was party in default or uncollectible2011-09-30No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2011-09-30$397,152
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2011-09-30$568,351
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2011-09-30$568,351
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2011-09-30$1,855
Expenses. Payments to insurance carriers foe the provision of benefits2011-09-30$567,792
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2011-09-30No
Was there a failure to transmit to the plan any participant contributions2011-09-30No
Has the plan failed to provide any benefit when due under the plan2011-09-30No
Contributions received in cash from employer2011-09-30$1,363,284
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2011-09-30$1,439,220
Contract administrator fees2011-09-30$43,410
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32011-09-30No
Liabilities. Value of benefit claims payable at end of year2011-09-30$297,428
Liabilities. Value of benefit claims payable at beginning of year2011-09-30$321,064
Did the plan have assets held for investment2011-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2011-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2011-09-30No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2011-09-30No
Opinion of an independent qualified public accountant for this plan2011-09-30Unqualified
Accountancy firm name2011-09-30MONROE SWEERIS & TROMP PLC
Accountancy firm EIN2011-09-30382621598
2010 : POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2010 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2010-09-30$321,064
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2010-09-30$369,402
Total income from all sources (including contributions)2010-09-30$1,874,004
Total of all expenses incurred2010-09-30$1,943,520
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2010-09-30$1,894,537
Total contributions o plan (from employers,participants, others, non cash contrinutions)2010-09-30$1,872,584
Value of total assets at end of year2010-09-30$568,351
Value of total assets at beginning of year2010-09-30$686,205
Total of administrative expenses incurred including professional, contract, advisory and management fees2010-09-30$48,983
Total interest from all sources2010-09-30$1,420
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2010-09-30No
Administrative expenses professional fees incurred2010-09-30$8,000
Was this plan covered by a fidelity bond2010-09-30Yes
Value of fidelity bond cover2010-09-30$500,000
If this is an individual account plan, was there a blackout period2010-09-30No
Were there any nonexempt tranactions with any party-in-interest2010-09-30No
Contributions received from participants2010-09-30$492,623
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2010-09-30No
Value of net income/loss2010-09-30$-69,516
Value of net assets at end of year (total assets less liabilities)2010-09-30$247,287
Value of net assets at beginning of year (total assets less liabilities)2010-09-30$316,803
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2010-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2010-09-30No
Were any leases to which the plan was party in default or uncollectible2010-09-30No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2010-09-30$568,351
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2010-09-30$686,205
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2010-09-30$686,205
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2010-09-30$1,420
Expenses. Payments to insurance carriers foe the provision of benefits2010-09-30$541,099
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2010-09-30No
Was there a failure to transmit to the plan any participant contributions2010-09-30No
Has the plan failed to provide any benefit when due under the plan2010-09-30No
Contributions received in cash from employer2010-09-30$1,379,961
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2010-09-30$1,353,438
Contract administrator fees2010-09-30$40,983
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32010-09-30No
Liabilities. Value of benefit claims payable at end of year2010-09-30$321,064
Liabilities. Value of benefit claims payable at beginning of year2010-09-30$369,402
Did the plan have assets held for investment2010-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2010-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2010-09-30No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2010-09-30No
Opinion of an independent qualified public accountant for this plan2010-09-30Unqualified
Accountancy firm name2010-09-30MONROE SWEERIS & TROMP PLC
Accountancy firm EIN2010-09-30382621598
2009 : POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2009 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2009-09-30$369,402
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2009-09-30$355,448
Total income from all sources (including contributions)2009-09-30$1,912,143
Total of all expenses incurred2009-09-30$1,789,326
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2009-09-30$1,735,151
Total contributions o plan (from employers,participants, others, non cash contrinutions)2009-09-30$1,910,399
Value of total assets at end of year2009-09-30$686,205
Value of total assets at beginning of year2009-09-30$549,434
Total of administrative expenses incurred including professional, contract, advisory and management fees2009-09-30$54,175
Total interest from all sources2009-09-30$1,744
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2009-09-30No
Administrative expenses professional fees incurred2009-09-30$8,000
Was this plan covered by a fidelity bond2009-09-30Yes
Value of fidelity bond cover2009-09-30$500,000
If this is an individual account plan, was there a blackout period2009-09-30No
Were there any nonexempt tranactions with any party-in-interest2009-09-30No
Contributions received from participants2009-09-30$466,243
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2009-09-30No
Value of net income/loss2009-09-30$122,817
Value of net assets at end of year (total assets less liabilities)2009-09-30$316,803
Value of net assets at beginning of year (total assets less liabilities)2009-09-30$193,986
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2009-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2009-09-30No
Were any leases to which the plan was party in default or uncollectible2009-09-30No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2009-09-30$686,205
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2009-09-30$549,434
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2009-09-30$549,434
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2009-09-30$1,744
Expenses. Payments to insurance carriers foe the provision of benefits2009-09-30$533,053
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2009-09-30No
Was there a failure to transmit to the plan any participant contributions2009-09-30No
Has the plan failed to provide any benefit when due under the plan2009-09-30No
Contributions received in cash from employer2009-09-30$1,444,156
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2009-09-30$1,202,098
Contract administrator fees2009-09-30$46,175
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32009-09-30No
Liabilities. Value of benefit claims payable at end of year2009-09-30$369,402
Liabilities. Value of benefit claims payable at beginning of year2009-09-30$355,448
Did the plan have assets held for investment2009-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2009-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2009-09-30No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2009-09-30No
Opinion of an independent qualified public accountant for this plan2009-09-30Unqualified
Accountancy firm name2009-09-30MONROE SWEERIS & TROMP PLC
Accountancy firm EIN2009-09-30382621598

Form 5500 Responses for POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN

2022: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT 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 funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan funding arrangement – TrustYes
2011-10-01Plan funding arrangement – General assets of the sponsorYes
2011-10-01Plan benefit arrangement – InsuranceYes
2011-10-01Plan benefit arrangement - TrustYes
2010: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01Submission has been amendedYes
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan funding arrangement – TrustYes
2010-10-01Plan funding arrangement – General assets of the sponsorYes
2010-10-01Plan benefit arrangement – InsuranceYes
2010-10-01Plan benefit arrangement - TrustYes
2009: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-10-01Type of plan entityMulti-employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan funding arrangement – TrustYes
2009-10-01Plan funding arrangement – General assets of the sponsorYes
2009-10-01Plan benefit arrangement – InsuranceYes
2009-10-01Plan benefit arrangement - TrustYes
2008: POLACK PRINTING, INC. DBA DIOCESAN PUBLISHING AND TRINITY NATIONAL WELFARE BENEFIT PLAN 2008 form 5500 responses
2008-10-01Type of plan entitySingle employer plan
2008-10-01Submission has been amendedYes
2008-10-01Plan funding arrangement – InsuranceYes
2008-10-01Plan funding arrangement – TrustYes
2008-10-01Plan funding arrangement – General assets of the sponsorYes
2008-10-01Plan benefit arrangement – InsuranceYes
2008-10-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number286876
Policy instance 1
Insurance contract or identification number286876
Number of Individuals Covered236
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $52,593
Total amount of fees paid to insurance companyUSD $1,540
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,593
Insurance broker organization code?3
Amount paid for insurance broker fees1540
Additional information about fees paid to insurance brokerFEES PAID
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberVEAB100232
Policy instance 2
Insurance contract or identification numberVEAB100232
Number of Individuals Covered165
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $14,784
Total amount of fees paid to insurance companyUSD $7,468
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
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $99,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,784
Amount paid for insurance broker fees7468
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0010506
Policy instance 3
Insurance contract or identification number0010506
Number of Individuals Covered199
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,844
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,844
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number286876
Policy instance 1
Insurance contract or identification number286876
Number of Individuals Covered234
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberVEAB100232
Policy instance 2
Insurance contract or identification numberVEAB100232
Number of Individuals Covered153
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $18,091
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
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 $122,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,091
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0010506
Policy instance 3
Insurance contract or identification number0010506
Number of Individuals Covered187
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,793
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,793
Insurance broker organization code?3

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