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GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 401k Plan overview

Plan NameGROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT
Plan identification number 502

GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

D.C. CENTRAL KITCHEN, INC. has sponsored the creation of one or more 401k plans.

Company Name:D.C. CENTRAL KITCHEN, INC.
Employer identification number (EIN):521584936
NAIC Classification:624200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022021-09-01GLENDA COGNEVICH2023-01-09
5022020-09-01GLENDA COGNEVICH2021-12-01
5022019-09-01GLENDA GOGNEVICH2021-01-13
5022018-09-01GLENDA COGNEVICH2019-12-17
5022017-09-01
5022016-09-01
5022015-09-01GLENDA COGNEVICH
5022014-09-01TOCHUKWU OKASI-MWORD
5022013-09-01GLENDA COGNEVICH
5022012-09-01GLENDA COGNEVICH
5022011-09-01GLENDA COGNEVICH

Plan Statistics for GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT

401k plan membership statisitcs for GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT

Measure Date Value
2021: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2021 401k membership
Total participants, beginning-of-year2021-09-01168
Total number of active participants reported on line 7a of the Form 55002021-09-01133
Number of retired or separated participants receiving benefits2021-09-010
Number of other retired or separated participants entitled to future benefits2021-09-010
Total of all active and inactive participants2021-09-01133
Number of employers contributing to the scheme2021-09-010
2020: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2020 401k membership
Total participants, beginning-of-year2020-09-01154
Total number of active participants reported on line 7a of the Form 55002020-09-01168
Number of retired or separated participants receiving benefits2020-09-010
Number of other retired or separated participants entitled to future benefits2020-09-010
Total of all active and inactive participants2020-09-01168
Number of employers contributing to the scheme2020-09-010
2019: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2019 401k membership
Total participants, beginning-of-year2019-09-01163
Total number of active participants reported on line 7a of the Form 55002019-09-01154
Number of retired or separated participants receiving benefits2019-09-010
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01154
Number of employers contributing to the scheme2019-09-010
2018: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2018 401k membership
Total participants, beginning-of-year2018-09-01163
Total number of active participants reported on line 7a of the Form 55002018-09-01163
Number of retired or separated participants receiving benefits2018-09-010
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01163
Number of employers contributing to the scheme2018-09-010
2017: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2017 401k membership
Total participants, beginning-of-year2017-09-01155
Total number of active participants reported on line 7a of the Form 55002017-09-01172
Number of retired or separated participants receiving benefits2017-09-010
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-01172
2016: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2016 401k membership
Total participants, beginning-of-year2016-09-01162
Total number of active participants reported on line 7a of the Form 55002016-09-01155
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01155
2015: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2015 401k membership
Total participants, beginning-of-year2015-09-01132
Total number of active participants reported on line 7a of the Form 55002015-09-01129
Number of retired or separated participants receiving benefits2015-09-010
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01129
2014: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2014 401k membership
Total participants, beginning-of-year2014-09-01124
Total number of active participants reported on line 7a of the Form 55002014-09-01132
Number of retired or separated participants receiving benefits2014-09-010
Number of other retired or separated participants entitled to future benefits2014-09-010
Total of all active and inactive participants2014-09-01132
2013: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2013 401k membership
Total participants, beginning-of-year2013-09-01114
Total number of active participants reported on line 7a of the Form 55002013-09-01124
Number of retired or separated participants receiving benefits2013-09-010
Number of other retired or separated participants entitled to future benefits2013-09-010
Total of all active and inactive participants2013-09-01124
2012: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2012 401k membership
Total participants, beginning-of-year2012-09-01109
Total number of active participants reported on line 7a of the Form 55002012-09-01114
Number of retired or separated participants receiving benefits2012-09-010
Number of other retired or separated participants entitled to future benefits2012-09-010
Total of all active and inactive participants2012-09-01114
2011: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2011 401k membership
Total participants, beginning-of-year2011-09-01139
Total number of active participants reported on line 7a of the Form 55002011-09-01101
Number of retired or separated participants receiving benefits2011-09-010
Number of other retired or separated participants entitled to future benefits2011-09-010
Total of all active and inactive participants2011-09-01101

Form 5500 Responses for GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT

2021: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2021 form 5500 responses
2021-09-01Type of plan entitySingle employer plan
2021-09-01Plan funding arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – InsuranceYes
2020: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – InsuranceYes
2019: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – InsuranceYes
2018: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – InsuranceYes
2017: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – InsuranceYes
2016: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – InsuranceYes
2015: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedNo
2015-09-01This submission is the final filingNo
2015-09-01This return/report is a short plan year return/report (less than 12 months)No
2015-09-01Plan is a collectively bargained planNo
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – InsuranceYes
2014: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2014 form 5500 responses
2014-09-01Type of plan entitySingle employer plan
2014-09-01Submission has been amendedNo
2014-09-01This submission is the final filingNo
2014-09-01This return/report is a short plan year return/report (less than 12 months)No
2014-09-01Plan is a collectively bargained planNo
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – InsuranceYes
2013: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2013 form 5500 responses
2013-09-01Type of plan entitySingle employer plan
2013-09-01Submission has been amendedNo
2013-09-01This submission is the final filingNo
2013-09-01This return/report is a short plan year return/report (less than 12 months)No
2013-09-01Plan is a collectively bargained planNo
2013-09-01Plan funding arrangement – InsuranceYes
2013-09-01Plan benefit arrangement – InsuranceYes
2012: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2012 form 5500 responses
2012-09-01Type of plan entitySingle employer plan
2012-09-01Submission has been amendedNo
2012-09-01This submission is the final filingNo
2012-09-01This return/report is a short plan year return/report (less than 12 months)No
2012-09-01Plan is a collectively bargained planNo
2012-09-01Plan funding arrangement – InsuranceYes
2012-09-01Plan benefit arrangement – InsuranceYes
2011: GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT 2011 form 5500 responses
2011-09-01Type of plan entitySingle employer plan
2011-09-01First time form 5500 has been submittedYes
2011-09-01Submission has been amendedNo
2011-09-01This submission is the final filingNo
2011-09-01This return/report is a short plan year return/report (less than 12 months)No
2011-09-01Plan is a collectively bargained planNo
2011-09-01Plan funding arrangement – InsuranceYes
2011-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BKTR
Policy instance 1
Insurance contract or identification numberGLTD0BKTR
Number of Individuals Covered133
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $9,186
Total amount of fees paid to insurance companyUSD $13,382
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $91,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,186
Amount paid for insurance broker fees8790
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BKTR
Policy instance 1
Insurance contract or identification numberGLTD0BKTR
Number of Individuals Covered168
Insurance policy start date2020-09-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,396
Total amount of fees paid to insurance companyUSD $1,698
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $30,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,396
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BKTR
Policy instance 1
Insurance contract or identification numberGLUG0BKTR
Number of Individuals Covered154
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $8,466
Total amount of fees paid to insurance companyUSD $5,571
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $84,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,053
Amount paid for insurance broker fees1334
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160386
Policy instance 1
Insurance contract or identification number160386
Number of Individuals Covered167
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $4,931
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,931
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160386
Policy instance 2
Insurance contract or identification number160386
Number of Individuals Covered167
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,690
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,690
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160386
Policy instance 3
Insurance contract or identification number160386
Number of Individuals Covered167
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $5,408
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,408
Amount paid for insurance broker fees0
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160386
Policy instance 1
Insurance contract or identification number160386
Number of Individuals Covered172
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $10,568
Total amount of fees paid to insurance companyUSD $1,015
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,568
Amount paid for insurance broker fees1015
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
Insurance broker nameKELLY AND ASSOCIATES INS. GROUP INC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160386
Policy instance 1
Insurance contract or identification number160386
Number of Individuals Covered129
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $4,295
Total amount of fees paid to insurance companyUSD $4,191
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 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 AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,295
Amount paid for insurance broker fees4191
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
Insurance broker nameKELLY AND ASSOC, INS. GROUP, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10179017
Policy instance 1
Insurance contract or identification number10179017
Number of Individuals Covered132
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $7,639
Total amount of fees paid to insurance companyUSD $2,847
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 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 AND 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 $57,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,639
Amount paid for insurance broker fees2847
Additional information about fees paid to insurance brokerBROKER BONUS FEES
Insurance broker organization code?3
Insurance broker nameKELLY AND ASSOCIATES INS. GROUP
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10179017
Policy instance 1
Insurance contract or identification number10179017
Number of Individuals Covered124
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $5,946
Total amount of fees paid to insurance companyUSD $3,369
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 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 AND 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 $41,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,946
Amount paid for insurance broker fees2078
Additional information about fees paid to insurance brokerTPA FEE
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberMG20726
Policy instance 1
Insurance contract or identification numberMG20726
Number of Individuals Covered114
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $3,157
Total amount of fees paid to insurance companyUSD $1,256
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 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 AND 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 $31,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,157
Amount paid for insurance broker fees1256
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameKELLY AND ASSOCIATES INS. GROUP
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberMG20726
Policy instance 1
Insurance contract or identification numberMG20726
Number of Individuals Covered101
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $4,561
Total amount of fees paid to insurance companyUSD $2,813
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 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 AND 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 $37,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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