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TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 401k Plan overview

Plan NameTOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN
Plan identification number 501

TOMPKINS PRODUCTS INC 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)
  • Other welfare benefit cover

401k Sponsoring company profile

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

Company Name:TOMPKINS PRODUCTS INC.
Employer identification number (EIN):382323649
NAIC Classification:333610

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-09-01RALPH STAELGRAEVE2023-01-17
5012020-09-01RALPH STAELGRAEVE2022-02-14
5012019-09-01RALPH STAELGRAEVE2020-12-02
5012016-09-01RALPH STAELGRAEVE

Plan Statistics for TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN

Measure Date Value
2021: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-01164
Total number of active participants reported on line 7a of the Form 55002021-09-01175
Total of all active and inactive participants2021-09-01175
2020: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01121
Total number of active participants reported on line 7a of the Form 55002020-09-01164
Total of all active and inactive participants2020-09-01164
2019: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01135
Total number of active participants reported on line 7a of the Form 55002019-09-01187
Total of all active and inactive participants2019-09-01187
2016: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01101
Total number of active participants reported on line 7a of the Form 55002016-09-01112
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01112

Form 5500 Responses for TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN

2021: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-09-01Type of plan entitySingle employer plan
2021-09-01Submission has been amendedNo
2021-09-01This submission is the final filingNo
2021-09-01This return/report is a short plan year return/report (less than 12 months)No
2021-09-01Plan is a collectively bargained planNo
2021-09-01Plan funding arrangement – InsuranceYes
2021-09-01Plan funding arrangement – General assets of the sponsorYes
2021-09-01Plan benefit arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – General assets of the sponsorYes
2020: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Submission has been amendedNo
2020-09-01This submission is the final filingNo
2020-09-01This return/report is a short plan year return/report (less than 12 months)No
2020-09-01Plan is a collectively bargained planNo
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan funding arrangement – General assets of the sponsorYes
2020-09-01Plan benefit arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – General assets of the sponsorYes
2019: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedNo
2019-09-01This submission is the final filingNo
2019-09-01This return/report is a short plan year return/report (less than 12 months)No
2019-09-01Plan is a collectively bargained planNo
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2016: TOMPKINS PRODUCTS INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01First time form 5500 has been submittedYes
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan funding arrangement – General assets of the sponsorYes
2016-09-01Plan benefit arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number796517
Policy instance 7
Insurance contract or identification number796517
Number of Individuals Covered124
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $21,975
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 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 $549,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,975
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5965565
Policy instance 5
Insurance contract or identification number5965565
Number of Individuals Covered175
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $28,729
Total amount of fees paid to insurance companyUSD $3,789
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
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 $147,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,529
Insurance broker organization code?3
Amount paid for insurance broker fees1952
Additional information about fees paid to insurance brokerFEES PAID
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0224152
Policy instance 4
Insurance contract or identification number0224152
Number of Individuals Covered23
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $1,587
Total amount of fees paid to insurance companyUSD $130
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 providedCRITICAL ILLNESS
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 $7,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,587
Insurance broker organization code?3
Amount paid for insurance broker fees130
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00157829/0001
Policy instance 3
Insurance contract or identification number00157829/0001
Number of Individuals Covered28
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $7,054
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 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 $144,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,433
Insurance broker organization code?3
AMFIRST INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60250 )
Policy contract number19910
Policy instance 2
Insurance contract or identification number19910
Number of Individuals Covered0
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $10,810
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 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 $46,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,663
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0224153
Policy instance 1
Insurance contract or identification number0224153
Number of Individuals Covered50
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $1,109
Total amount of fees paid to insurance companyUSD $93
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 providedACCIDENT
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 $5,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,109
Insurance broker organization code?3
Amount paid for insurance broker fees93
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )
Policy contract numberT6034820
Policy instance 5
Insurance contract or identification numberT6034820
Number of Individuals Covered118
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $22,358
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
Welfare Benefit Premiums Paid to CarrierUSD $481,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,358
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5965565
Policy instance 3
Insurance contract or identification number5965565
Number of Individuals Covered164
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $26,911
Total amount of fees paid to insurance companyUSD $4,893
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
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 $108,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,008
Insurance broker organization code?3
Amount paid for insurance broker fees1222
Additional information about fees paid to insurance brokerFEES PAID
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00157829/0001
Policy instance 2
Insurance contract or identification number00157829/0001
Number of Individuals Covered32
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $9,595
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 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 $199,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,923
Insurance broker organization code?3
AMFIRST INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60250 )
Policy contract number19910
Policy instance 1
Insurance contract or identification number19910
Number of Individuals Covered51
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $12,253
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 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 $52,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,273
Insurance broker organization code?3
TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )
Policy contract numberT6034820
Policy instance 5
Insurance contract or identification numberT6034820
Number of Individuals Covered132
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $17,915
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
Welfare Benefit Premiums Paid to CarrierUSD $579,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,915
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5965565
Policy instance 3
Insurance contract or identification number5965565
Number of Individuals Covered187
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $28,285
Total amount of fees paid to insurance companyUSD $4,997
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
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 $133,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,068
Amount paid for insurance broker fees1444
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00157829/0001
Policy instance 2
Insurance contract or identification number00157829/0001
Number of Individuals Covered40
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $13,233
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 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 $186,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,986
Insurance broker organization code?3
AMFIRST INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60250 )
Policy contract number19910
Policy instance 1
Insurance contract or identification number19910
Number of Individuals Covered51
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $11,701
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 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 $11,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,961
Insurance broker organization code?3

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