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KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameKESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN
Plan identification number 501

KESWICK PINES DBA THE PINES AT WHITING 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)
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

KESWICK PINES has sponsored the creation of one or more 401k plans.

Company Name:KESWICK PINES
Employer identification number (EIN):521761391
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01RONALD SCULLY2023-04-21
5012020-10-01ERIC GHAUL2022-04-13
5012019-10-01ERIC GHAUL2021-03-05
5012019-04-01ERIC GHAUL2020-07-13
5012018-04-01ERIC GHAUL2019-12-17
5012017-04-01
5012016-04-01
5012015-04-01ERIC GHAUL

Plan Statistics for KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN

401k plan membership statisitcs for KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN

Measure Date Value
2021: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01105
Total number of active participants reported on line 7a of the Form 55002021-10-010
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-010
Number of employers contributing to the scheme2021-10-010
2020: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01112
Total number of active participants reported on line 7a of the Form 55002020-10-01105
Number of retired or separated participants receiving benefits2020-10-010
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01105
Number of employers contributing to the scheme2020-10-010
2019: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01114
Total number of active participants reported on line 7a of the Form 55002019-10-01112
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01112
Number of employers contributing to the scheme2019-10-010
Total participants, beginning-of-year2019-04-01111
Total number of active participants reported on line 7a of the Form 55002019-04-01114
Number of retired or separated participants receiving benefits2019-04-010
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01114
Number of employers contributing to the scheme2019-04-010
2018: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01108
Total number of active participants reported on line 7a of the Form 55002018-04-01111
Number of retired or separated participants receiving benefits2018-04-010
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01111
Number of employers contributing to the scheme2018-04-010
2017: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01108
Total number of active participants reported on line 7a of the Form 55002017-04-01103
Number of retired or separated participants receiving benefits2017-04-011
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01104
2016: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01110
Total number of active participants reported on line 7a of the Form 55002016-04-01108
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01108
2015: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01100
Total number of active participants reported on line 7a of the Form 55002015-04-01110
Number of retired or separated participants receiving benefits2015-04-010
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01110

Form 5500 Responses for KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN

2021: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01This submission is the final filingYes
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – General assets of the sponsorYes
2020: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2019-04-01Type of plan entitySingle employer plan
2019-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – InsuranceYes
2018: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – InsuranceYes
2017: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – InsuranceYes
2016: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: KESWICK PINES DBA THE PINES AT WHITING HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01First time form 5500 has been submittedYes
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30104014
Policy instance 3
Insurance contract or identification number30104014
Number of Individuals Covered106
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $895
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $795
Amount paid for insurance broker fees0
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number5331
Policy instance 2
Insurance contract or identification number5331
Number of Individuals Covered99
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $1,372
Total amount of fees paid to insurance companyUSD $708
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $9,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,266
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number96747
Policy instance 1
Insurance contract or identification number96747
Number of Individuals Covered87
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $3,254
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,254
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508
Policy instance 3
Insurance contract or identification number4106508
Number of Individuals Covered119
Insurance policy start date2020-10-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $1,051
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
Welfare Benefit Premiums Paid to CarrierUSD $13,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,051
Amount paid for insurance broker fees0
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number5331
Policy instance 2
Insurance contract or identification number5331
Number of Individuals Covered105
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $1,343
Total amount of fees paid to insurance companyUSD $677
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,343
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number96747
Policy instance 1
Insurance contract or identification number96747
Number of Individuals Covered109
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $3,428
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $78,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,428
Amount paid for insurance broker fees0
Insurance broker organization code?3
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number96747
Policy instance 1
Insurance contract or identification number96747
Number of Individuals Covered113
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $3,801
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $79,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,801
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508
Policy instance 2
Insurance contract or identification number4106508
Number of Individuals Covered112
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $857
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $857
Amount paid for insurance broker fees0
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number5331
Policy instance 3
Insurance contract or identification number5331
Number of Individuals Covered109
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $1,309
Total amount of fees paid to insurance companyUSD $776
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees776
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508
Policy instance 1
Insurance contract or identification number4106508
Number of Individuals Covered113
Insurance policy start date2019-04-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $410
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $410
Amount paid for insurance broker fees0
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number5331
Policy instance 2
Insurance contract or identification number5331
Number of Individuals Covered114
Insurance policy start date2019-04-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $646
Total amount of fees paid to insurance companyUSD $651
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $4,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees651
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508
Policy instance 3
Insurance contract or identification number4106508
Number of Individuals Covered110
Insurance policy start date2019-09-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $79
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79
Amount paid for insurance broker fees0
Insurance broker organization code?3
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number96747
Policy instance 4
Insurance contract or identification number96747
Number of Individuals Covered320
Insurance policy start date2019-04-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $17,673
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $595,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,717
Amount paid for insurance broker fees0
Insurance broker organization code?3
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number80198
Policy instance 4
Insurance contract or identification number80198
Number of Individuals Covered107
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $39,432
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $1,105,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,432
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4767208
Policy instance 3
Insurance contract or identification numberE4767208
Number of Individuals Covered38
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $5,649
Total amount of fees paid to insurance companyUSD $1,705
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $34,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,850
Amount paid for insurance broker fees767
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50021596
Policy instance 2
Insurance contract or identification number50021596
Number of Individuals Covered111
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $1,240
Total amount of fees paid to insurance companyUSD $576
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,240
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508-V0894
Policy instance 1
Insurance contract or identification number4106508-V0894
Number of Individuals Covered118
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $925
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $925
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberNFP160
Policy instance 1
Insurance contract or identification numberNFP160
Number of Individuals Covered100
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508-V0894
Policy instance 2
Insurance contract or identification number4106508-V0894
Number of Individuals Covered109
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $915
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $915
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAFETZ AND ASSOCIATES, LLC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50021596
Policy instance 3
Insurance contract or identification number50021596
Number of Individuals Covered104
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,231
Total amount of fees paid to insurance companyUSD $566
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,231
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameHORIZON INSURANCE COMPANY
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number80198
Policy instance 4
Insurance contract or identification number80198
Number of Individuals Covered102
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $52,106
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $1,058,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,106
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHAFETZ AND ASSOCIATES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number4106508-V0894
Policy instance 4
Insurance contract or identification number4106508-V0894
Number of Individuals Covered108
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $919
Total amount of fees paid to insurance companyUSD $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 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 $13,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $919
Insurance broker organization code?3
Insurance broker nameHAFETZ AND ASSOCIATES, LLC
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberNFP160
Policy instance 3
Insurance contract or identification numberNFP160
Number of Individuals Covered1125
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?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 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 $6,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50021596
Policy instance 2
Insurance contract or identification number50021596
Number of Individuals Covered110
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $1,092
Total amount of fees paid to insurance companyUSD $450
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 BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDDENTAL 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 $7,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,092
Insurance broker organization code?3
Amount paid for insurance broker fees450
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameHORIZON INSURANCE COMPANY
HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 )
Policy contract number80198/96747
Policy instance 1
Insurance contract or identification number80198/96747
Number of Individuals Covered105
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $67,578
Total amount of fees paid to insurance companyUSD $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 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 $943,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $67,578
Insurance broker organization code?3
Insurance broker nameHAFETZ AND ASSOCIATES, LLC

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