PENNANT FOODS CORPORATION has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2017: PENNANT FOODS CORPORATION 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 343 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 0 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 0 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: PENNANT FOODS CORPORATION 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 343 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 343 |
| 2015: PENNANT FOODS CORPORATION 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 271 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 271 |
| 2014: PENNANT FOODS CORPORATION 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 261 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 353 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 353 |
| 2013: PENNANT FOODS CORPORATION 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 231 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 227 |
| Number of retired or separated participants receiving benefits | 2013-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-01 | 0 |
| Total of all active and inactive participants | 2013-12-01 | 227 |
| 2012: PENNANT FOODS CORPORATION 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 231 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 231 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 231 |
| 2017: PENNANT FOODS CORPORATION 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | This submission is the final filing | Yes |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PENNANT FOODS CORPORATION 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PENNANT FOODS CORPORATION 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PENNANT FOODS CORPORATION 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PENNANT FOODS CORPORATION 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PENNANT FOODS CORPORATION 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 ) |
| Policy contract number | 5481397 |
| Policy instance | 2 |
| Insurance contract or identification number | 5481397 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $179 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $179 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS AND INSURANCE SVCS. |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5481397 |
| Policy instance | 1 |
| Insurance contract or identification number | 5481397 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $1,146 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $14,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,146 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS AND INSURANCE SVCS. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00507798 |
| Policy instance | 3 |
| Insurance contract or identification number | 00507798 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $3,197 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, VOLUNTARY CRITICAL 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 Carrier | USD $27,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,197 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00388728 |
| Policy instance | 2 |
| Insurance contract or identification number | 00388728 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $28,463 | | Total amount of fees paid to insurance company | USD $7,798 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D; ACCIDENT; VOLUNTARY CRITICAL ILLNESS; OPTIONAL LIFE | | 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 Carrier | USD $245,248 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,463 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 110011 |
| Policy instance | 1 |
| Insurance contract or identification number | 110011 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $45,409 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $5,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,409 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | COLE HARRIS |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00388728 |
| Policy instance | 2 |
| Insurance contract or identification number | 00388728 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $30,840 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D; ACCIDENT; VOLUNTARY CRITICAL ILLNESS; OPTIONAL LIFE | | 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 Carrier | USD $263,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,014 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 110011 |
| Policy instance | 1 |
| Insurance contract or identification number | 110011 | | Number of Individuals Covered | 388 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $42,567 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $7,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,567 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | COLE HARRIS |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00388728 |
| Policy instance | 5 |
| Insurance contract or identification number | 00388728 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $10,921 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D; ACCIDENT; VOLUNTARY CRITICAL ILLNESS; OPTIONAL LIFE | | 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 Carrier | USD $127,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,483 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1010440 |
| Policy instance | 4 |
| Insurance contract or identification number | 1010440 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $1,945 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $12,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,204 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C20938 |
| Policy instance | 3 |
| Insurance contract or identification number | C20938 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $34,288 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $542,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,257 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INS. SERVICES, INC. |
|
| GOLDEN WEST HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 276640 |
| Policy instance | 2 |
| Insurance contract or identification number | 276640 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $1,627 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $17,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,077 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INS. SERVICES, INC. |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 110011 |
| Policy instance | 1 |
| Insurance contract or identification number | 110011 | | Number of Individuals Covered | 403 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $30,877 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $765,573 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,075 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | COLE HARRIS |
|
