SHELBYVILLE LAUNDRY INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2023: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 948 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 1,811 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 1,822 |
| 2022: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 818 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 933 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 935 |
| 2021: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 844 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 824 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 826 |
| 2016: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 230 |
| Total of all active and inactive participants | 2016-09-01 | 230 |
| Total participants | 2016-09-01 | 230 |
| 2015: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 229 |
| Total of all active and inactive participants | 2015-09-01 | 229 |
| Total participants | 2015-09-01 | 229 |
| 2014: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 177 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 218 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 218 |
| Total participants | 2014-09-01 | 218 |
| 2013: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 181 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 175 |
| Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 2 |
| Total of all active and inactive participants | 2013-09-01 | 177 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-09-01 | 0 |
| Total participants | 2013-09-01 | 177 |
| 2012: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 179 |
| Number of retired or separated participants receiving benefits | 2012-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 2 |
| Total of all active and inactive participants | 2012-09-01 | 181 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-09-01 | 0 |
| Total participants | 2012-09-01 | 181 |
| Total participants, beginning-of-year | 2012-01-01 | 201 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 183 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 183 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-01-01 | 0 |
| Total participants | 2012-01-01 | 183 |
| 2011: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 199 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 201 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-01-01 | 0 |
| Total participants | 2011-01-01 | 201 |
| 2010: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 174 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 170 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 171 |
| Total participants | 2010-01-01 | 171 |
| 2009: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 172 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 174 |
| Total participants | 2009-01-01 | 174 |
| 2023: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | No |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | No |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | Yes |
| 2016-09-01 | This submission is the final filing | Yes |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00024570 |
| Policy instance | 2 |
| Insurance contract or identification number | 00024570 | | Number of Individuals Covered | 1770 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-30 | | Total amount of commissions paid to insurance broker | USD $36,401 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOL. ACCIDENT, AD&D, VOL. AD&D, VOL. CRITICAL ILLNESS, VOL. LIFE, VOL HOSPITAL INDEMNITY | | 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 Carrier | USD $231,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0928487 |
| Policy instance | 1 |
| Insurance contract or identification number | 0928487 | | Number of Individuals Covered | 750 | | Insurance policy start date | 2023-09-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $9,316 | | Total amount of fees paid to insurance company | USD $139,086 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $4,198,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00024570 |
| Policy instance | 5 |
| Insurance contract or identification number | 00024570 | | Number of Individuals Covered | 898 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-30 | | Total amount of commissions paid to insurance broker | USD $60,129 | | Total amount of fees paid to insurance company | USD $5,465 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY ACCIDENT, AD&D, OPTIONAL AD&D, VOL CRITICAL ILLNESS, OPTIONAL LIFE | | 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 Carrier | USD $177,573 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41071 |
| Policy instance | 4 |
| Insurance contract or identification number | 41071 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $2,036 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $25,633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 54715 |
| Policy instance | 3 |
| Insurance contract or identification number | 54715 | | Number of Individuals Covered | 426 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $7,709 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
| Policy contract number | L03552 |
| Policy instance | 2 |
| Insurance contract or identification number | L03552 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $123,162 | | Total amount of fees paid to insurance company | USD $5,000 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $3,054,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0928487 |
| Policy instance | 1 |
| Insurance contract or identification number | 0928487 | | Number of Individuals Covered | 1223 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,515 | | Total amount of fees paid to insurance company | USD $37,486 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,698,686 | | 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 | GLTD0BF4N |
| Policy instance | 12 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00024570 |
| Policy instance | 11 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BF4N |
| Policy instance | 10 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BF4N |
| Policy instance | 9 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 888790G |
| Policy instance | 8 |
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41071 |
| Policy instance | 7 |
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 41071 |
| Policy instance | 6 |
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 54715 |
| Policy instance | 5 |
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 54715 |
| Policy instance | 4 |
| COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
| Policy contract number | L03552 |
| Policy instance | 3 |
| BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
| Policy contract number | L03552 |
| Policy instance | 2 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0905405 |
| Policy instance | 1 |
