DAVIS FURNITURE INDUSTRIES, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN
401k plan membership statisitcs for DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-05-01 | 225 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 255 |
| Number of retired or separated participants receiving benefits | 2022-05-01 | 0 |
| Total of all active and inactive participants | 2022-05-01 | 255 |
| 2021: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-05-01 | 240 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 224 |
| Number of retired or separated participants receiving benefits | 2021-05-01 | 1 |
| Total of all active and inactive participants | 2021-05-01 | 225 |
| 2020: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-05-01 | 249 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 239 |
| Number of retired or separated participants receiving benefits | 2020-05-01 | 1 |
| Total of all active and inactive participants | 2020-05-01 | 240 |
| 2019: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-05-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 246 |
| Number of retired or separated participants receiving benefits | 2019-05-01 | 1 |
| Total of all active and inactive participants | 2019-05-01 | 247 |
| 2018: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 235 |
| Number of retired or separated participants receiving benefits | 2018-05-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 5 |
| Total of all active and inactive participants | 2018-05-01 | 241 |
| 2017: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 210 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 219 |
| Total of all active and inactive participants | 2017-05-01 | 219 |
| 2016: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 210 |
| Number of retired or separated participants receiving benefits | 2016-05-01 | 1 |
| Total of all active and inactive participants | 2016-05-01 | 211 |
| 2015: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 187 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 1 |
| Total of all active and inactive participants | 2015-05-01 | 188 |
| 2014: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 166 |
| Number of retired or separated participants receiving benefits | 2014-05-01 | 1 |
| Total of all active and inactive participants | 2014-05-01 | 167 |
| 2013: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 163 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 2 |
| Total of all active and inactive participants | 2013-05-01 | 165 |
| 2012: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 142 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 2 |
| Total of all active and inactive participants | 2012-05-01 | 144 |
| 2011: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 125 |
| Number of retired or separated participants receiving benefits | 2011-05-01 | 2 |
| Total of all active and inactive participants | 2011-05-01 | 127 |
| 2009: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 167 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 112 |
| Total of all active and inactive participants | 2009-05-01 | 112 |
| 2022: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-05-01 | Type of plan entity | Single employer plan |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Submission has been amended | Yes |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | Submission has been amended | Yes |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: DAVIS FURNITURE INDUSTRIES, INC. EMPLOYEE INSURANCE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | This submission is the final filing | No |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00021407 |
| Policy instance | 1 |
| Insurance contract or identification number | 00021407 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $14,630 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $95,444 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,935 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00021407 |
| Policy instance | 1 |
| Insurance contract or identification number | 00021407 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $7,410 | | Total amount of fees paid to insurance company | USD $1,839 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $74,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,410 | | Amount paid for insurance broker fees | 1839 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00021407 |
| Policy instance | 1 |
| Insurance contract or identification number | 00021407 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,972 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $49,716 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,972 | | Insurance broker organization code? | 4 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 1 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,200 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,200 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOBJT4 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTDOBJT4 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $1,900 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,001 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,900 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BJT4 |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0BJT4 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $3,716 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,716 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BJT4 |
| Policy instance | 4 |
| Insurance contract or identification number | GUG0BJT4 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $2,695 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,695 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 2 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,143 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,223 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,143 | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $8,418 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $84,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,418 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 2 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,096 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $7,775 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $77,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $6,368 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $63,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,368 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 2 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $972 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $972 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 3 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $925 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $925 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $5,298 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $52,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,298 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 1730P2 |
| Policy instance | 2 |
| Insurance contract or identification number | 1730P2 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $3,869 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,869 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30037734 |
| Policy instance | 3 |
| Insurance contract or identification number | 30037734 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $883 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $883 | | Insurance broker name | HPB INSURANCE GROUP |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $4,274 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $42,740 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,274 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 1730P2 |
| Policy instance | 2 |
| Insurance contract or identification number | 1730P2 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $3,543 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,857 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,543 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00612001 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00612001 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $4,398 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $38,536 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,398 | | Insurance broker organization code? | 3 | | Insurance broker name | HPB INSURANCE GROUP |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 1000375 |
| Policy instance | 3 |
| Insurance contract or identification number | 1000375 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 1730P2 |
| Policy instance | 2 |
| Insurance contract or identification number | 1730P2 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $5,769 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,302 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDS B BROOKBANK |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 1730P2 |
| Policy instance | 2 |
| Insurance contract or identification number | 1730P2 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $5,425 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 3623W6 |
| Policy instance | 1 |
| Insurance contract or identification number | 3623W6 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $4,075 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $36,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOAAGY |
| Policy instance | 2 |
| Insurance contract or identification number | GLUGOAAGY | | Number of Individuals Covered | 115 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $1,566 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOAAGY |
| Policy instance | 1 |
| Insurance contract or identification number | GUGOAAGY | | Number of Individuals Covered | 114 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $1,382 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOAAGY |
| Policy instance | 3 |
| Insurance contract or identification number | GLTDOAAGY | | Number of Individuals Covered | 36 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $1,339 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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