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POWDER COTE II PREMIUM CONVERSION PLAN 401k Plan overview

Plan NamePOWDER COTE II PREMIUM CONVERSION PLAN
Plan identification number 501

POWDER COTE II PREMIUM CONVERSION PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

POWDER COTE II has sponsored the creation of one or more 401k plans.

Company Name:POWDER COTE II
Employer identification number (EIN):382622430
NAIC Classification:541990
NAIC Description:All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POWDER COTE II PREMIUM CONVERSION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01CHARLES TROTT2023-08-28
5012021-01-01CHARLES TROTT2022-04-11
5012020-01-01CHARLES TROTT2021-08-31
5012019-01-01CHARLES TROTT2020-06-26
5012018-01-01CHARLES TROTT2019-07-19
5012017-01-01
5012016-01-01
5012015-01-01
5012014-01-01
5012013-01-01
5012012-01-01CHARLES TROTT
5012011-01-01CHARLES TROTT
5012009-01-01CHARLIE TROTT

Plan Statistics for POWDER COTE II PREMIUM CONVERSION PLAN

401k plan membership statisitcs for POWDER COTE II PREMIUM CONVERSION PLAN

Measure Date Value
2022: POWDER COTE II PREMIUM CONVERSION PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01226
Total number of active participants reported on line 7a of the Form 55002022-01-01295
Total of all active and inactive participants2022-01-01295
2021: POWDER COTE II PREMIUM CONVERSION PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01262
Total number of active participants reported on line 7a of the Form 55002021-01-01226
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01226
2020: POWDER COTE II PREMIUM CONVERSION PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01259
Total number of active participants reported on line 7a of the Form 55002020-01-01262
Total of all active and inactive participants2020-01-01262
2019: POWDER COTE II PREMIUM CONVERSION PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01264
Total number of active participants reported on line 7a of the Form 55002019-01-01259
Total of all active and inactive participants2019-01-01259
2018: POWDER COTE II PREMIUM CONVERSION PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01303
Total number of active participants reported on line 7a of the Form 55002018-01-01264
Total of all active and inactive participants2018-01-01264
2017: POWDER COTE II PREMIUM CONVERSION PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01298
Total number of active participants reported on line 7a of the Form 55002017-01-01303
Total of all active and inactive participants2017-01-01303
2016: POWDER COTE II PREMIUM CONVERSION PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01301
Total number of active participants reported on line 7a of the Form 55002016-01-01298
Total of all active and inactive participants2016-01-01298
2015: POWDER COTE II PREMIUM CONVERSION PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01327
Total number of active participants reported on line 7a of the Form 55002015-01-01301
Total of all active and inactive participants2015-01-01301
2014: POWDER COTE II PREMIUM CONVERSION PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01309
Total number of active participants reported on line 7a of the Form 55002014-01-01327
Total of all active and inactive participants2014-01-01327
2013: POWDER COTE II PREMIUM CONVERSION PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01331
Total number of active participants reported on line 7a of the Form 55002013-01-01309
Total of all active and inactive participants2013-01-01309
2012: POWDER COTE II PREMIUM CONVERSION PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01223
Total number of active participants reported on line 7a of the Form 55002012-01-01331
Total of all active and inactive participants2012-01-01331
2011: POWDER COTE II PREMIUM CONVERSION PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01188
Total number of active participants reported on line 7a of the Form 55002011-01-01223
Total of all active and inactive participants2011-01-01223
2009: POWDER COTE II PREMIUM CONVERSION PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01147
Total number of active participants reported on line 7a of the Form 55002009-01-01105
Total of all active and inactive participants2009-01-01105

Form 5500 Responses for POWDER COTE II PREMIUM CONVERSION PLAN

2022: POWDER COTE II PREMIUM CONVERSION PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
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: POWDER COTE II PREMIUM CONVERSION PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
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
2020: POWDER COTE II PREMIUM CONVERSION PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: POWDER COTE II PREMIUM CONVERSION PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: POWDER COTE II PREMIUM CONVERSION PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: POWDER COTE II PREMIUM CONVERSION PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: POWDER COTE II PREMIUM CONVERSION PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: POWDER COTE II PREMIUM CONVERSION PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: POWDER COTE II PREMIUM CONVERSION PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: POWDER COTE II PREMIUM CONVERSION PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: POWDER COTE II PREMIUM CONVERSION PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: POWDER COTE II PREMIUM CONVERSION PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: POWDER COTE II PREMIUM CONVERSION PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

REGENCY EMPLOYEE BENEFITS (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number79018 / 671
Policy instance 2
Insurance contract or identification number79018 / 671
Number of Individuals Covered96
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $46,464
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $647,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees46464
Additional information about fees paid to insurance brokerADMINISTRATION FEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BMM7
Policy instance 1
Insurance contract or identification numberG000BMM7
Number of Individuals Covered295
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,678
Total amount of fees paid to insurance companyUSD $1,718
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $20,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,678
Amount paid for insurance broker fees669
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BMM7
Policy instance 1
Insurance contract or identification numberG000BMM7
Number of Individuals Covered226
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,530
Total amount of fees paid to insurance companyUSD $1,141
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $19,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,530
Amount paid for insurance broker fees1141
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
REGENCY EMPLOYEE BENEFITS (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number79018 / 671
Policy instance 2
Insurance contract or identification number79018 / 671
Number of Individuals Covered97
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 $46,464
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $720,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees46464
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
REGENCY EMPLOYEE BENEFITS (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number79018 / 671
Policy instance 2
Insurance contract or identification number79018 / 671
Number of Individuals Covered111
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $46,464
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $772,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees46464
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BMM7
Policy instance 1
Insurance contract or identification numberG000BMM7
Number of Individuals Covered262
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,702
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $21,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,702
Amount paid for insurance broker fees0
Insurance broker organization code?3
REGENCY EMPLOYEE BENEFITS (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number79018 / 671
Policy instance 2
Insurance contract or identification number79018 / 671
Number of Individuals Covered114
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $46,464
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $735,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees46464
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05925674
Policy instance 1
Insurance contract or identification numberTM05925674
Number of Individuals Covered259
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,598
Total amount of fees paid to insurance companyUSD $148
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $17,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,598
Amount paid for insurance broker fees148
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05925674
Policy instance 1
Insurance contract or identification numberTM05925674
Number of Individuals Covered303
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,705
Total amount of fees paid to insurance companyUSD $785
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $19,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,705
Amount paid for insurance broker fees785
Additional information about fees paid to insurance brokerSUPPLEMENTAL AND NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05925674
Policy instance 1
Insurance contract or identification numberTM05925674
Number of Individuals Covered301
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,645
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $19,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,645
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AHQR
Policy instance 2
Insurance contract or identification numberGVTL0AHQR
Number of Individuals Covered31
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,069
Total amount of fees paid to insurance companyUSD $187
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D - VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $7,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,069
Amount paid for insurance broker fees187
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AHQR
Policy instance 1
Insurance contract or identification numberGLUG0AHQR
Number of Individuals Covered327
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $2,863
Total amount of fees paid to insurance companyUSD $692
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $28,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,863
Amount paid for insurance broker fees692
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AHQR
Policy instance 1
Insurance contract or identification numberGLUG0AHQR
Number of Individuals Covered309
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $2,868
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $28,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,868
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AHQR
Policy instance 2
Insurance contract or identification numberGVTL0AHQR
Number of Individuals Covered32
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $1,191
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D - VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $7,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,191
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AHQR
Policy instance 2
Insurance contract or identification numberG000AHQR
Number of Individuals Covered38
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $1,845
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D - VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $8,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,845
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AHQR
Policy instance 1
Insurance contract or identification numberG000AHQR
Number of Individuals Covered331
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $3,834
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $26,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,834
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameACRISURE LLC
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number689934G
Policy instance 2
Insurance contract or identification number689934G
Number of Individuals Covered223
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $544
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $2,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberADDS05318
Policy instance 1
Insurance contract or identification numberADDS05318
Number of Individuals Covered223
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $110
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number10694
Policy instance 3
Insurance contract or identification number10694
Number of Individuals Covered206
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $16,949
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Were dividends or retroactive rate refunds paid in cash?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,949
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameROBBINS & MARCOZZI, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number689934G
Policy instance 2
Insurance contract or identification number689934G
Number of Individuals Covered188
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $6,144
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $32,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,144
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameROBBINS & MARCOZZI, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberADDS05318
Policy instance 1
Insurance contract or identification numberADDS05318
Number of Individuals Covered188
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $679
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $679
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameROBBINS & MARCOZZI, INC.

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