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GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN
Plan identification number 503

GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Other welfare benefit cover

401k Sponsoring company profile

GBB SERVICES, LLC has sponsored the creation of one or more 401k plans.

Company Name:GBB SERVICES, LLC
Employer identification number (EIN):611733264
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Additional information about GBB SERVICES, LLC

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2014-03-18
Company Identification Number: 0801954295
Legal Registered Office Address: 14881 FM 2154 UNIT 190

WELLBORN
United States of America (USA)
77881

More information about GBB SERVICES, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032021-05-01
5032020-05-01
5032019-05-01
5032018-05-01
5032017-05-01NATALIE PRICE
5032016-05-01NATALIE PRICE

Plan Statistics for GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN

401k plan membership statisitcs for GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN

Measure Date Value
2021: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01136
Total number of active participants reported on line 7a of the Form 55002021-05-010
Number of retired or separated participants receiving benefits2021-05-010
Number of other retired or separated participants entitled to future benefits2021-05-010
Total of all active and inactive participants2021-05-010
2020: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01254
Total number of active participants reported on line 7a of the Form 55002020-05-01116
Number of retired or separated participants receiving benefits2020-05-010
Number of other retired or separated participants entitled to future benefits2020-05-010
Total of all active and inactive participants2020-05-01116
2019: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01195
Total number of active participants reported on line 7a of the Form 55002019-05-01254
Number of retired or separated participants receiving benefits2019-05-013
Number of other retired or separated participants entitled to future benefits2019-05-010
Total of all active and inactive participants2019-05-01257
2018: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01185
Total number of active participants reported on line 7a of the Form 55002018-05-01195
Number of retired or separated participants receiving benefits2018-05-013
Number of other retired or separated participants entitled to future benefits2018-05-010
Total of all active and inactive participants2018-05-01198
2017: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01196
Total number of active participants reported on line 7a of the Form 55002017-05-01196
Number of retired or separated participants receiving benefits2017-05-012
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-01198
2016: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01168
Total number of active participants reported on line 7a of the Form 55002016-05-01196
Number of retired or separated participants receiving benefits2016-05-010
Number of other retired or separated participants entitled to future benefits2016-05-010
Total of all active and inactive participants2016-05-01196

Form 5500 Responses for GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN

2021: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Submission has been amendedYes
2021-05-01This submission is the final filingYes
2021-05-01This return/report is a short plan year return/report (less than 12 months)No
2021-05-01Plan is a collectively bargained planNo
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – InsuranceYes
2020: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Submission has been amendedNo
2020-05-01This submission is the final filingNo
2020-05-01This return/report is a short plan year return/report (less than 12 months)No
2020-05-01Plan is a collectively bargained planNo
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – InsuranceYes
2019: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Submission has been amendedNo
2019-05-01This submission is the final filingNo
2019-05-01This return/report is a short plan year return/report (less than 12 months)No
2019-05-01Plan is a collectively bargained planNo
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – InsuranceYes
2018: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Submission has been amendedNo
2018-05-01This submission is the final filingNo
2018-05-01This return/report is a short plan year return/report (less than 12 months)No
2018-05-01Plan is a collectively bargained planNo
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – InsuranceYes
2017: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Submission has been amendedNo
2017-05-01This submission is the final filingNo
2017-05-01This return/report is a short plan year return/report (less than 12 months)No
2017-05-01Plan is a collectively bargained planNo
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – InsuranceYes
2016: GBB SERVICES, LLC EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01First time form 5500 has been submittedYes
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDS0BWBT
Policy instance 4
Insurance contract or identification numberGUDS0BWBT
Number of Individuals Covered55
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $2,749
Total amount of fees paid to insurance companyUSD $283
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 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 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 $27,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,000
Amount paid for insurance broker fees283
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BWBT
Policy instance 3
Insurance contract or identification numberGLUG0BWBT
Number of Individuals Covered136
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $567
Total amount of fees paid to insurance companyUSD $132
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 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 providedAD&D
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 $5,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $421
Amount paid for insurance broker fees132
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLLV0BWBT
Policy instance 2
Insurance contract or identification numberGLLV0BWBT
Number of Individuals Covered43
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $630
Total amount of fees paid to insurance companyUSD $134
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 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 $6,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $461
Amount paid for insurance broker fees134
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number115854
Policy instance 1
Insurance contract or identification number115854
Number of Individuals Covered74
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $11,139
Total amount of fees paid to insurance companyUSD $4,883
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 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 $1,176,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,393
Insurance broker organization code?3
Amount paid for insurance broker fees4883
Additional information about fees paid to insurance brokerFEES
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number115854
Policy instance 2
Insurance contract or identification number115854
Number of Individuals Covered95
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $25,835
Total amount of fees paid to insurance companyUSD $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 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 $464,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,362
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF015078
Policy instance 1
Insurance contract or identification numberF015078
Number of Individuals Covered116
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $1,152
Total amount of fees paid to insurance companyUSD $500
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 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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 $9,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,152
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF015078
Policy instance 1
Insurance contract or identification numberF015078
Number of Individuals Covered254
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $2,496
Total amount of fees paid to insurance companyUSD $994
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 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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 $23,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,496
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number115854
Policy instance 2
Insurance contract or identification number115854
Number of Individuals Covered79
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $27,821
Total amount of fees paid to insurance companyUSD $6,759
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 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 $533,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,293
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number115854
Policy instance 2
Insurance contract or identification number115854
Number of Individuals Covered127
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $35,942
Total amount of fees paid to insurance companyUSD $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 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 $529,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,694
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF015078
Policy instance 1
Insurance contract or identification numberF015078
Number of Individuals Covered195
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $2,235
Total amount of fees paid to insurance companyUSD $889
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 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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 $16,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,235
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number115854
Policy instance 3
Insurance contract or identification number115854
Number of Individuals Covered99
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $33,871
Total amount of fees paid to insurance companyUSD $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 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 $447,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,131
Insurance broker organization code?3
Insurance broker nameROGERS BENEFITS GROUP
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF015078
Policy instance 2
Insurance contract or identification numberF015078
Number of Individuals Covered196
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $1,372
Total amount of fees paid to insurance companyUSD $457
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 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 providedADD
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 $8,942
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,372
Insurance broker organization code?3
Amount paid for insurance broker fees457
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameROGERS BENEFIT GROUP INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number658693
Policy instance 1
Insurance contract or identification number658693
Number of Individuals Covered60
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $722
Total amount of fees paid to insurance companyUSD $131
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 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 $7,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $722
Amount paid for insurance broker fees131
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBALDWIN KRYSTYN SHERMAN PARTNERS

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