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| Plan Name | BOSAL AMERICA, INC. MEDICAL, DENTAL, LIFE AND DISABILITY PROGRAM |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BOSAL INDUSTRIES GEORGIA, INC. |
| Employer identification number (EIN): | 593281175 |
| NAIC Classification: | 336300 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2018-01-01 | AMY DAVIS | |||
| 501 | 2017-01-01 | AMY DAVIS |
| 2018: BOSAL AMERICA, INC. MEDICAL, DENTAL, LIFE AND DISABILITY PROGRAM 2018 form 5500 responses | ||
|---|---|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: BOSAL AMERICA, INC. MEDICAL, DENTAL, LIFE AND DISABILITY PROGRAM 2017 form 5500 responses | ||
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 876256G |
| Policy instance | 1 |
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) | |
| Policy contract number | 6081 |
| Policy instance | 2 |
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) | |
| Policy contract number | 195546 |
| Policy instance | 3 |
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) | |
| Policy contract number | 195546 |
| Policy instance | 4 |
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) | |
| Policy contract number | 6081 |
| Policy instance | 1 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) | |
| Policy contract number | 876256G |
| Policy instance | 2 |
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) | |
| Policy contract number | 00195546/0002 |
| Policy instance | 3 |
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) | |
| Policy contract number | 0170 |
| Policy instance | 4 |
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