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PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 401k Plan overview

Plan NamePETE'S FRESH MARKET HEALTH AND WELFARE PLAN
Plan identification number 501

PETE'S FRESH MARKET HEALTH AND WELFARE 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

GM WAREHOUSE INC. DBA PETES FRESH MARKET has sponsored the creation of one or more 401k plans.

Company Name:GM WAREHOUSE INC. DBA PETES FRESH MARKET
Employer identification number (EIN):450539235
NAIC Classification:424400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PETE'S FRESH MARKET HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-07-01MIRIAM ECHEVARRIA2022-12-30
5012020-07-01
5012020-07-01
5012019-07-01
5012018-07-01
5012017-07-01VANESSA DREMONAS
5012016-07-01VANESSA DREMONAS
5012015-07-01VANESSA DREMONAS

Plan Statistics for PETE'S FRESH MARKET HEALTH AND WELFARE PLAN

401k plan membership statisitcs for PETE'S FRESH MARKET HEALTH AND WELFARE PLAN

Measure Date Value
2021: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01932
Total number of active participants reported on line 7a of the Form 55002021-07-01917
Number of retired or separated participants receiving benefits2021-07-018
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01925
2020: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01908
Total number of active participants reported on line 7a of the Form 55002020-07-01904
Number of retired or separated participants receiving benefits2020-07-015
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01909
2019: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-011,103
Total number of active participants reported on line 7a of the Form 55002019-07-011,097
Number of retired or separated participants receiving benefits2019-07-012
Number of other retired or separated participants entitled to future benefits2019-07-0132
Total of all active and inactive participants2019-07-011,131
2018: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-011,462
Total number of active participants reported on line 7a of the Form 55002018-07-01916
Number of retired or separated participants receiving benefits2018-07-015
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01921
2017: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-011,400
Total number of active participants reported on line 7a of the Form 55002017-07-01562
Number of retired or separated participants receiving benefits2017-07-013
Number of other retired or separated participants entitled to future benefits2017-07-0127
Total of all active and inactive participants2017-07-01592
2016: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-011,518
Total number of active participants reported on line 7a of the Form 55002016-07-01657
Number of retired or separated participants receiving benefits2016-07-011
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01658
2015: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-011,185
Total number of active participants reported on line 7a of the Form 55002015-07-01497
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01497

Form 5500 Responses for PETE'S FRESH MARKET HEALTH AND WELFARE PLAN

2021: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – InsuranceYes
2018: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Submission has been amendedNo
2018-07-01This submission is the final filingNo
2018-07-01This return/report is a short plan year return/report (less than 12 months)No
2018-07-01Plan is a collectively bargained planNo
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – InsuranceYes
2017: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Submission has been amendedNo
2017-07-01This submission is the final filingNo
2017-07-01This return/report is a short plan year return/report (less than 12 months)No
2017-07-01Plan is a collectively bargained planNo
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2016: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – InsuranceYes
2015: PETE'S FRESH MARKET HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01First time form 5500 has been submittedYes
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122961
Policy instance 4
Insurance contract or identification number122961
Number of Individuals Covered866
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $142,867
Total amount of fees paid to insurance companyUSD $27,918
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 $5,449,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $142,867
Amount paid for insurance broker fees8676
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0241458
Policy instance 3
Insurance contract or identification number0241458
Number of Individuals Covered1720
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $20,584
Total amount of fees paid to insurance companyUSD $5,146
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
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 $550,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,584
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number946275
Policy instance 2
Insurance contract or identification number946275
Number of Individuals Covered666
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $66,158
Total amount of fees paid to insurance companyUSD $4,745
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 providedAD&D, ACCIDENT, 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 CarrierUSD $521,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $66,148
Amount paid for insurance broker fees4745
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number1011713,1011737
Policy instance 1
Insurance contract or identification number1011713,1011737
Number of Individuals Covered907
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $4,514
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 $40,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,514
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number946275
Policy instance 3
Insurance contract or identification number946275
Number of Individuals Covered665
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $81,311
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 providedAD&D, ACCIDENT, 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 CarrierUSD $502,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,159
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10117131001
Policy instance 2
Insurance contract or identification number10117131001
Number of Individuals Covered907
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $7,201
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 $61,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $988
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122961
Policy instance 1
Insurance contract or identification number122961
Number of Individuals Covered1201
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $160,306
Total amount of fees paid to insurance companyUSD $5,034
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
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 $5,693,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,716
Amount paid for insurance broker fees5034
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number248577
Policy instance 3
Insurance contract or identification number248577
Number of Individuals Covered655
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $71,599
Total amount of fees paid to insurance companyUSD $6,245
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 providedCRITICAL ILLNESS, ACCIDENT, AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $471,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71,599
Amount paid for insurance broker fees6245
Additional information about fees paid to insurance brokerBONUS AMOUNT
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10117131001
Policy instance 2
Insurance contract or identification number10117131001
Number of Individuals Covered914
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $5,939
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 $60,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,939
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122961
Policy instance 1
Insurance contract or identification number122961
Number of Individuals Covered1215
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $187,287
Total amount of fees paid to insurance companyUSD $9,360
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
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 $5,515,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $187,287
Amount paid for insurance broker fees9360
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number248577
Policy instance 3
Insurance contract or identification number248577
Number of Individuals Covered507
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $54,375
Total amount of fees paid to insurance companyUSD $12,962
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 providedACCIDENT INSURANCE,CHILD & SPOUSE CRITICAL ILLNESS, VOL LIFE & AD&D, EE CRITICAL ILLNESS, VOL LIFE &AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $324,883
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,375
Amount paid for insurance broker fees12962
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122961
Policy instance 2
Insurance contract or identification number122961
Number of Individuals Covered1086
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $161,449
Total amount of fees paid to insurance companyUSD $7,428
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 BenefitYes
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 $4,723,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $161,449
Amount paid for insurance broker fees7428
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10117131001
Policy instance 1
Insurance contract or identification number10117131001
Number of Individuals Covered792
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,962
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 $50,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,962
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number248577
Policy instance 3
Insurance contract or identification number248577
Number of Individuals Covered507
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $45,988
Total amount of fees paid to insurance companyUSD $14,525
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 providedACCIDENT INSURANCE,CHILD & SPOUSE CRITICAL ILLNESS, VOL LIFE & AD&D, EE CRITICAL ILLNESS, VOL LIFE &AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $325,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,988
Insurance broker organization code?3
Amount paid for insurance broker fees14525
Additional information about fees paid to insurance brokerBONUS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122961
Policy instance 2
Insurance contract or identification number122961
Number of Individuals Covered959
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $141,224
Total amount of fees paid to insurance companyUSD $6,924
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 BenefitYes
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 $4,168,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $141,224
Amount paid for insurance broker fees6924
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10117131001
Policy instance 1
Insurance contract or identification number10117131001
Number of Individuals Covered697
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,061
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 $42,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,059
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number248577
Policy instance 3
Insurance contract or identification number248577
Number of Individuals Covered507
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $37,119
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 providedACCIDENT INSURANCE,CHILD & SPOUSE CRITICAL ILLNESS, VOL LIFE & AD&D, EE CRITICAL ILLNESS, VOL LIFE &AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $275,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,119
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFITS SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number122554
Policy instance 2
Insurance contract or identification number122554
Number of Individuals Covered870
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $121,367
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 BenefitYes
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 $3,370,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115,778
Insurance broker organization code?3
Insurance broker nameAXION RMS, LTD.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10117131001
Policy instance 1
Insurance contract or identification number10117131001
Number of Individuals Covered597
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $3,970
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 $40,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,639
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFITS SERVICES, INC.

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