401k Plan data: LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN plan

LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN
Plan identification number	501

LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

LATITUDE SUBROGATION SERVICES, LLC has sponsored the creation of one or more 401k plans.

Company Name: LATITUDE SUBROGATION SERVICES, LLC

Employer identification number (EIN): 383569761

NAIC Classification: 524290

Additional information about LATITUDE SUBROGATION SERVICES, LLC

Jurisdiction of Incorporation: Michigan Department of Licensing & Regulatory Affairs

Incorporation Date:

Company Identification Number: B70210

More information about LATITUDE SUBROGATION SERVICES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-11-01 JON COSCIA 2023-05-25

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-11-01	JON COSCIA	2023-05-25

Plan Statistics for LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN

401k plan membership statisitcs for LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN

Measure Date Value
2021: LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-11-01 93
Total number of active participants reported on line 7a of the Form 5500 2021-11-01 105
Number of retired or separated participants receiving benefits 2021-11-01 1
Total of all active and inactive participants 2021-11-01 106

Measure	Date	Value
2021: LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-11-01	93
Total number of active participants reported on line 7a of the Form 5500	2021-11-01	105
Number of retired or separated participants receiving benefits	2021-11-01	1
Total of all active and inactive participants	2021-11-01	106

Form 5500 Responses for LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN

2021: LATITUDE SUBROGATION SERVICES WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-11-01	Type of plan entity	Single employer plan
2021-11-01	First time form 5500 has been submitted	Yes
2021-11-01	Plan funding arrangement – Insurance	Yes
2021-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-11-01	Plan benefit arrangement – Insurance	Yes
2021-11-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AMCV

Policy instance

Insurance contract or identification number	GLUG0AMCV
Number of Individuals Covered	105
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $951
Total amount of fees paid to insurance company	USD $488
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $530
Amount paid for insurance broker fees	488
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AMCV

Policy instance

Insurance contract or identification number	GLTD0AMCV
Number of Individuals Covered	105
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $1,464
Total amount of fees paid to insurance company	USD $749
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $816
Amount paid for insurance broker fees	749
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AMCV

Policy instance

Insurance contract or identification number	GVTL0AMCV
Number of Individuals Covered	41
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $3,241
Total amount of fees paid to insurance company	USD $2,195
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $32,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,938
Amount paid for insurance broker fees	2195
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

418514

Policy instance

Insurance contract or identification number	418514
Number of Individuals Covered	144
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $50,024
Total amount of fees paid to insurance company	USD $877
Health 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 $46,946
Insurance broker organization code?	3
Amount paid for insurance broker fees	877

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30022300

Policy instance

Insurance contract or identification number	30022300
Number of Individuals Covered	71
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $739
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $739

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0AMCV

Policy instance

Insurance contract or identification number	GUG 0AMCV
Number of Individuals Covered	105
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $2,493
Total amount of fees paid to insurance company	USD $1,302
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,398
Amount paid for insurance broker fees	1302
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0AMCV

Policy instance

Insurance contract or identification number	GUDS0AMCV
Number of Individuals Covered	80
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $5,990
Total amount of fees paid to insurance company	USD $1,661
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,513
Amount paid for insurance broker fees	1661
Insurance broker organization code?	3

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Company Name:	LATITUDE SUBROGATION SERVICES, LLC
Employer identification number (EIN):	383569761
NAIC Classification:	524290

Jurisdiction of Incorporation:	Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number:	B70210