ULTIMATE HYDROFORMING, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN
401k plan membership statisitcs for ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN
| Measure | Date | Value |
|---|
| 2022: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 150 |
| Total of all active and inactive participants | 2022-03-01 | 150 |
| Total participants | 2022-03-01 | 150 |
| 2021: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 158 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 158 |
| Total participants | 2021-03-01 | 158 |
| 2020: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 139 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 139 |
| Total participants | 2020-03-01 | 139 |
| 2019: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 143 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 143 |
| Total participants | 2019-03-01 | 143 |
| 2018: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 127 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 127 |
| Total participants | 2018-03-01 | 128 |
| 2017: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 115 |
| Total of all active and inactive participants | 2017-03-01 | 115 |
| 2016: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 113 |
| Total of all active and inactive participants | 2016-03-01 | 113 |
| 2015: ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 101 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 114 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 114 |
| Measure | Date | Value |
|---|
| 2023 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2023 401k financial data |
|---|
| Total income from all sources (including contributions) | 2023-02-28 | $2,117,375 |
| Total of all expenses incurred | 2023-02-28 | $2,117,375 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2023-02-28 | $2,117,375 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2023-02-28 | $2,117,375 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2023-02-28 | No |
| Was this plan covered by a fidelity bond | 2023-02-28 | No |
| If this is an individual account plan, was there a blackout period | 2023-02-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2023-02-28 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-02-28 | No |
| Value of net income/loss | 2023-02-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2023-02-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2023-02-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2023-02-28 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2023-02-28 | $2,117,375 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2023-02-28 | No |
| Was there a failure to transmit to the plan any participant contributions | 2023-02-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2023-02-28 | No |
| Contributions received in cash from employer | 2023-02-28 | $2,117,375 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2023-02-28 | No |
| Did the plan have assets held for investment | 2023-02-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-02-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2023-02-28 | No |
| 2022 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2022 401k financial data |
|---|
| Total income from all sources (including contributions) | 2022-02-28 | $1,624,460 |
| Total of all expenses incurred | 2022-02-28 | $1,624,460 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-02-28 | $1,624,460 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-02-28 | $1,624,460 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-02-28 | No |
| Was this plan covered by a fidelity bond | 2022-02-28 | No |
| If this is an individual account plan, was there a blackout period | 2022-02-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-02-28 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-02-28 | No |
| Value of net income/loss | 2022-02-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-02-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-02-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-02-28 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-02-28 | $1,624,460 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-02-28 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-02-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-02-28 | No |
| Contributions received in cash from employer | 2022-02-28 | $1,624,460 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-02-28 | No |
| Did the plan have assets held for investment | 2022-02-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-02-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-02-28 | No |
| 2021 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2021 401k financial data |
|---|
| Total income from all sources (including contributions) | 2021-02-28 | $1,910,375 |
| Total of all expenses incurred | 2021-02-28 | $1,910,375 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-02-28 | $1,910,375 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-02-28 | $1,910,375 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-02-28 | No |
| Was this plan covered by a fidelity bond | 2021-02-28 | No |
| If this is an individual account plan, was there a blackout period | 2021-02-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-02-28 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-02-28 | No |
| Value of net income/loss | 2021-02-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-02-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-02-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-02-28 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-02-28 | $1,910,375 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-02-28 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-02-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-02-28 | No |
| Contributions received in cash from employer | 2021-02-28 | $1,910,375 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-02-28 | No |
| Did the plan have assets held for investment | 2021-02-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-02-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-02-28 | No |
| 2020 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2020 401k financial data |
|---|
| Total income from all sources (including contributions) | 2020-02-29 | $1,973,748 |
| Total of all expenses incurred | 2020-02-29 | $1,973,748 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-02-29 | $1,973,748 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-02-29 | $1,973,748 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-02-29 | No |
| Was this plan covered by a fidelity bond | 2020-02-29 | No |
| If this is an individual account plan, was there a blackout period | 2020-02-29 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-02-29 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-02-29 | No |
| Value of net income/loss | 2020-02-29 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-02-29 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-02-29 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-02-29 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-02-29 | $1,973,748 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-02-29 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-02-29 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-02-29 | No |
| Contributions received in cash from employer | 2020-02-29 | $1,973,748 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-02-29 | No |
| Did the plan have assets held for investment | 2020-02-29 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-02-29 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-02-29 | No |
| 2018 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2018 401k financial data |
|---|
| Total income from all sources (including contributions) | 2018-02-28 | $1,791,811 |
| Total of all expenses incurred | 2018-02-28 | $1,791,811 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-02-28 | $1,791,811 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-02-28 | $1,791,811 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-02-28 | No |
| Was this plan covered by a fidelity bond | 2018-02-28 | No |
| If this is an individual account plan, was there a blackout period | 2018-02-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-02-28 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-02-28 | No |
| Value of net income/loss | 2018-02-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-02-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-02-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-02-28 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-02-28 | $1,791,811 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-02-28 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-02-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-02-28 | No |
| Contributions received in cash from employer | 2018-02-28 | $1,791,811 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-02-28 | No |
| Did the plan have assets held for investment | 2018-02-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-02-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-02-28 | No |
| 2017 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2017 401k financial data |
|---|
| Total income from all sources (including contributions) | 2017-02-28 | $1,635,838 |
| Total of all expenses incurred | 2017-02-28 | $1,635,838 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-02-28 | $1,635,838 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-02-28 | $1,635,838 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-02-28 | No |
| Was this plan covered by a fidelity bond | 2017-02-28 | No |
| If this is an individual account plan, was there a blackout period | 2017-02-28 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-02-28 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-02-28 | No |
| Value of net income/loss | 2017-02-28 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-02-28 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-02-28 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-02-28 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-02-28 | $1,635,838 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-02-28 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-02-28 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-02-28 | No |
| Contributions received in cash from employer | 2017-02-28 | $1,635,838 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-02-28 | No |
| Did the plan have assets held for investment | 2017-02-28 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-02-28 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-02-28 | No |
| 2016 : ULTIMATE HYDROFORMING, INC. EMPLOYEE'S HEALTH & DENTAL PLAN 2016 401k financial data |
|---|
| Total income from all sources (including contributions) | 2016-02-29 | $1,576,960 |
| Total of all expenses incurred | 2016-02-29 | $1,576,960 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-02-29 | $1,576,960 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-02-29 | $1,576,960 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-02-29 | No |
| Was this plan covered by a fidelity bond | 2016-02-29 | No |
| If this is an individual account plan, was there a blackout period | 2016-02-29 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-02-29 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-02-29 | No |
| Value of net income/loss | 2016-02-29 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-02-29 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-02-29 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-02-29 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-02-29 | $1,576,960 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-02-29 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-02-29 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-02-29 | No |
| Contributions received in cash from employer | 2016-02-29 | $1,576,960 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2016-02-29 | No |
| Did the plan have assets held for investment | 2016-02-29 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-02-29 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-02-29 | No |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10214011001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10214011001 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $2,174 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,174 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1124639 |
| Policy instance | 4 |
| Insurance contract or identification number | 1124639 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $9,295 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,706 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,295 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $5,672 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,672 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 ) |
| Policy contract number | 10005465 |
| Policy instance | 2 |
| Insurance contract or identification number | 10005465 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $7,815 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $195,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,815 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 ) |
| Policy contract number | 10005464 |
| Policy instance | 1 |
| Insurance contract or identification number | 10005464 | | Number of Individuals Covered | 321 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $68,572 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,714,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,572 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 ) |
| Policy contract number | 10005464 |
| Policy instance | 1 |
| Insurance contract or identification number | 10005464 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $61,117 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,273,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,117 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 ) |
| Policy contract number | 10005465 |
| Policy instance | 2 |
| Insurance contract or identification number | 10005465 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $6,579 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $149,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,579 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $9,449 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,449 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1124639 |
| Policy instance | 4 |
| Insurance contract or identification number | 1124639 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $8,138 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,138 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10214011001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10214011001 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $2,130 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,130 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10214011001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10214011001 | | Number of Individuals Covered | 315 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $2,113 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,882 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,113 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1124639 |
| Policy instance | 4 |
| Insurance contract or identification number | 1124639 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $8,193 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,193 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $10,745 | | Total amount of fees paid to insurance company | USD $184 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,745 | | Amount paid for insurance broker fees | 184 | | Insurance broker organization code? | 3 |
|
| ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 ) |
| Policy contract number | 10005465 |
| Policy instance | 2 |
| Insurance contract or identification number | 10005465 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $8,459 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $211,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,459 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 ) |
| Policy contract number | 10005464 |
| Policy instance | 1 |
| Insurance contract or identification number | 10005464 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $56,191 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,507,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,191 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 158560 |
| Policy instance | 1 |
| Insurance contract or identification number | 158560 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $11,187 | | Total amount of fees paid to insurance company | USD $464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,187 | | Amount paid for insurance broker fees | 464 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 158560 |
| Policy instance | 2 |
| Insurance contract or identification number | 158560 | | Number of Individuals Covered | 326 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $57,528 | | Total amount of fees paid to insurance company | USD $5,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,528 | | Amount paid for insurance broker fees | 5116 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10214011001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10214011001 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $1,692 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,692 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200227 |
| Policy instance | 4 |
| Insurance contract or identification number | 200227 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $6,495 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $108,587 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,495 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $10,631 | | Total amount of fees paid to insurance company | USD $270 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,631 | | Amount paid for insurance broker fees | 270 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $8,580 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,580 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 158560 |
| Policy instance | 2 |
| Insurance contract or identification number | 158560 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $50,759 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,313,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,759 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 158560 |
| Policy instance | 1 |
| Insurance contract or identification number | 158560 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $9,892 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $256,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,892 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $9,683 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,683 | | Insurance broker organization code? | 3 | | Insurance broker name | BRSI EMPLOYEE BENEFIT SOLUTIONS |
|
| HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 ) |
| Policy contract number | 10000967 |
| Policy instance | 2 |
| Insurance contract or identification number | 10000967 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $56,686 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,417,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,573 | | Insurance broker name | BENEFIT REVIEW SERVICES, INC |
|
| ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 ) |
| Policy contract number | 10004280 |
| Policy instance | 1 |
| Insurance contract or identification number | 10004280 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $11,414 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $285,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,414 | | Insurance broker name | BRSI EMPLOYEE BENEFIT SOLUTIONS |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001955 |
| Policy instance | 3 |
| Insurance contract or identification number | 0001955 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $8,264 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,264 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT REVIEW SERVICES, INC |
|
| HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 ) |
| Policy contract number | 10000967 |
| Policy instance | 2 |
| Insurance contract or identification number | 10000967 | | Number of Individuals Covered | 219 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $37,925 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,086,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,925 | | Insurance broker name | BENEFIT REVIEW SERVICES, INC |
|
| ALLIANCE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60134 ) |
| Policy contract number | 10004280 |
| Policy instance | 1 |
| Insurance contract or identification number | 10004280 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $16,681 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $409,557 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,681 | | Insurance broker name | BENEFIT REVIEW SERVICES, INC |
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