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GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number 504

GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

GENESIS INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:GENESIS INDUSTRIES, INC.
Employer identification number (EIN):391538522
NAIC Classification:325200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5042022-01-01DENELL HELLER2023-06-17
5042021-01-01JEANNINE EDGREN2022-08-03
5042020-01-01
5042020-01-01
5042020-01-01
5042020-01-01
5042019-01-01ROSE GEIST2020-07-23

Plan Statistics for GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2022: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01216
Total number of active participants reported on line 7a of the Form 55002022-01-01238
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01238
2021: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01175
Total number of active participants reported on line 7a of the Form 55002021-01-01216
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 participants2021-01-01216
2020: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01185
Total number of active participants reported on line 7a of the Form 55002020-01-01174
Number of retired or separated participants receiving benefits2020-01-011
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01175
2019: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01177
Total number of active participants reported on line 7a of the Form 55002019-01-01183
Number of retired or separated participants receiving benefits2019-01-012
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01185

Form 5500 Responses for GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN

2022: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedYes
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
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: GENESIS INDUSTRIES EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01First time form 5500 has been submittedYes
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
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

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number08696A
Policy instance 6
Insurance contract or identification number08696A
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $303
Total amount of fees paid to insurance companyUSD $0
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 providedMEDICAL BENEFITS ABROAD
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 $3,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $303
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2032
Policy instance 5
Insurance contract or identification numberWI2032
Number of Individuals Covered213
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 $0
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 $2,060,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2032
Policy instance 4
Insurance contract or identification numberWI2032
Number of Individuals Covered29
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 $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 $383,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBD075
Policy instance 3
Insurance contract or identification numberBD075
Number of Individuals Covered135
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $28,046
Total amount of fees paid to insurance companyUSD $69
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT, CANCER, HOSPITAL, DISABILITY
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 $150,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,128
Amount paid for insurance broker fees47
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00555498
Policy instance 2
Insurance contract or identification number00555498
Number of Individuals Covered238
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,825
Total amount of fees paid to insurance companyUSD $965
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $72,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,825
Amount paid for insurance broker fees965
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30062478
Policy instance 1
Insurance contract or identification number30062478
Number of Individuals Covered138
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,759
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
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 $17,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,759
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number08696A
Policy instance 6
Insurance contract or identification number08696A
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $303
Total amount of fees paid to insurance companyUSD $0
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 providedMEDICAL BENEFITS ABROAD
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 $3,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $303
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2032
Policy instance 5
Insurance contract or identification numberWI2032
Number of Individuals Covered216
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 $1,631,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2032
Policy instance 4
Insurance contract or identification numberWI2032
Number of Individuals Covered32
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
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 $244,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBD075
Policy instance 3
Insurance contract or identification numberBD075
Number of Individuals Covered133
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,646
Total amount of fees paid to insurance companyUSD $536
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT, CANCER, HOSPITAL, DISABILITY
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 $116,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,657
Amount paid for insurance broker fees365
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00555498
Policy instance 2
Insurance contract or identification number00555498
Number of Individuals Covered216
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,984
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $53,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,984
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30062478
Policy instance 1
Insurance contract or identification number30062478
Number of Individuals Covered130
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,315
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
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 $13,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,315
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract numberWI2032
Policy instance 5
Insurance contract or identification numberWI2032
Number of Individuals Covered167
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 $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 $1,381,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2032
Policy instance 4
Insurance contract or identification numberWI2032
Number of Individuals Covered23
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 $0
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 $200,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBD075
Policy instance 3
Insurance contract or identification numberBD075
Number of Individuals Covered117
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $18,787
Total amount of fees paid to insurance companyUSD $684
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,CANCER, HOSPITAL, LIFE, DISABILITY
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 $123,084
Commission paid to Insurance BrokerUSD $11,756
Amount paid for insurance broker fees453
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00555498
Policy instance 2
Insurance contract or identification number00555498
Number of Individuals Covered174
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $6,273
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 $41,818
Commission paid to Insurance BrokerUSD $6,273
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30062478
Policy instance 1
Insurance contract or identification number30062478
Number of Individuals Covered101
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,272
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
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 $12,712
Commission paid to Insurance BrokerUSD $1,272
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30062478
Policy instance 2
Insurance contract or identification number30062478
Number of Individuals Covered116
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,016
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare 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 $11,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,016
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00555498
Policy instance 1
Insurance contract or identification number00555498
Number of Individuals Covered183
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,184
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $47,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,184
Insurance broker organization code?3

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