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REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 401k Plan overview

Plan NameREVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN
Plan identification number 501

REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)

401k Sponsoring company profile

REVOLUTION TECHNOLOGIES LLC has sponsored the creation of one or more 401k plans.

Company Name:REVOLUTION TECHNOLOGIES LLC
Employer identification number (EIN):651129030
NAIC Classification:541990
NAIC Description:All Other Professional, Scientific, and Technical Services

Additional information about REVOLUTION TECHNOLOGIES LLC

Jurisdiction of Incorporation: Nevada Department of State
Incorporation Date: 2006-03-17
Company Identification Number: 20061572730
Legal Registered Office Address: 2905 LAKE EAST DR STE 150

LAS VEGAS
United States of America (USA)
89117

More information about REVOLUTION TECHNOLOGIES LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01JASON DECRISTOFORO2023-07-12
5012020-10-01AERIAL SLOCUM2022-04-20
5012019-10-01AERIAL SLOCUM2021-01-28
5012018-10-01AERIAL SHARPE2020-02-03
5012017-10-01
5012016-10-01
5012016-10-01AERIAL SHARPE2019-06-20
5012015-10-01KENT SMITH
5012015-10-01AERIAL SHARPE2019-06-20
5012014-10-01KENT SMITH
5012014-10-01
5012013-10-01KENT SMITH
5012013-10-01

Plan Statistics for REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN

401k plan membership statisitcs for REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN

Measure Date Value
2021: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01179
Total number of active participants reported on line 7a of the Form 55002021-10-01176
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01176
Number of employers contributing to the scheme2021-10-010
2020: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01156
Total number of active participants reported on line 7a of the Form 55002020-10-01179
Number of retired or separated participants receiving benefits2020-10-010
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01179
Number of employers contributing to the scheme2020-10-010
2019: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01172
Total number of active participants reported on line 7a of the Form 55002019-10-01156
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01156
Number of employers contributing to the scheme2019-10-010
2018: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01145
Total number of active participants reported on line 7a of the Form 55002018-10-01172
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-01172
Number of employers contributing to the scheme2018-10-010
2017: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01145
Total number of active participants reported on line 7a of the Form 55002017-10-01145
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01145
Number of employers contributing to the scheme2017-10-010
2016: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01172
Total number of active participants reported on line 7a of the Form 55002016-10-01148
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01148
Number of employers contributing to the scheme2016-10-010
2015: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01186
Total number of active participants reported on line 7a of the Form 55002015-10-01172
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01172
Number of employers contributing to the scheme2015-10-010
2014: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-10-01149
Total number of active participants reported on line 7a of the Form 55002014-10-01186
Number of retired or separated participants receiving benefits2014-10-010
Number of other retired or separated participants entitled to future benefits2014-10-010
Total of all active and inactive participants2014-10-01186
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-10-010
Number of employers contributing to the scheme2014-10-010
2013: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01142
Total number of active participants reported on line 7a of the Form 55002013-10-01149
Number of retired or separated participants receiving benefits2013-10-010
Number of other retired or separated participants entitled to future benefits2013-10-010
Total of all active and inactive participants2013-10-01149
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-10-010
Number of employers contributing to the scheme2013-10-010

Form 5500 Responses for REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN

2021: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – General assets of the sponsorYes
2017: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – General assets of the sponsorYes
2016: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2014: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – InsuranceYes
2014-10-01Plan benefit arrangement – InsuranceYes
2013: REVOLUTION TECHNOLOGIES WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01First time form 5500 has been submittedYes
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number49392
Policy instance 5
Insurance contract or identification number49392
Number of Individuals Covered88
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $7,368
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENT, CRITICAL ILLNESS,HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $29,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,368
Amount paid for insurance broker fees0
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number633538
Policy instance 1
Insurance contract or identification number633538
Number of Individuals Covered139
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $50,016
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,410,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees50016
Additional information about fees paid to insurance brokerBENEFIT ADVISOR FEE
Insurance broker organization code?3
TELADOC, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )
Policy contract number158917
Policy instance 3
Insurance contract or identification number158917
Number of Individuals Covered156
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $87
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedTELEHEALTH
Welfare Benefit Premiums Paid to CarrierUSD $8,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $87
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number553176
Policy instance 2
Insurance contract or identification number553176
Number of Individuals Covered176
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $14,217
Total amount of fees paid to insurance companyUSD $6,660
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $135,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,217
Amount paid for insurance broker fees6660
Additional information about fees paid to insurance brokerFEE
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberRETECGX20211507
Policy instance 4
Insurance contract or identification numberRETECGX20211507
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number553176
Policy instance 1
Insurance contract or identification number553176
Number of Individuals Covered179
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $11,811
Total amount of fees paid to insurance companyUSD $1,682
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $108,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,811
Amount paid for insurance broker fees1682
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number553176
Policy instance 1
Insurance contract or identification number553176
Number of Individuals Covered156
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $12,708
Total amount of fees paid to insurance companyUSD $4,102
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,783
Amount paid for insurance broker fees4102
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number553176
Policy instance 1
Insurance contract or identification number553176
Number of Individuals Covered172
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $14,414
Total amount of fees paid to insurance companyUSD $2,470
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $128,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,414
Amount paid for insurance broker fees2470
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05318776
Policy instance 1
Insurance contract or identification numberTS05318776
Number of Individuals Covered359
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $13,851
Total amount of fees paid to insurance companyUSD $2,049
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,445
Amount paid for insurance broker fees51
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05318776
Policy instance 1
Insurance contract or identification numberTS05318776
Number of Individuals Covered490
Insurance policy start date2015-12-01
Insurance policy end date2016-11-30
Total amount of commissions paid to insurance brokerUSD $20,528
Total amount of fees paid to insurance companyUSD $7,997
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $131,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,528
Amount paid for insurance broker fees6514
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?5
Insurance broker nameJOHNSON AND BRYAN INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number417003411914
Policy instance 2
Insurance contract or identification number417003411914
Number of Individuals Covered172
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
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 $177,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract number417002411914
Policy instance 1
Insurance contract or identification number417002411914
Number of Individuals Covered186
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
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 $154,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5318776
Policy instance 2
Insurance contract or identification number5318776
Number of Individuals Covered159
Insurance policy start date2014-12-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $17,795
Total amount of fees paid to insurance companyUSD $11,231
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,150
Amount paid for insurance broker fees8150
Additional information about fees paid to insurance brokerADMINISTRATION FEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTS05318776
Policy instance 2
Insurance contract or identification numberTS05318776
Number of Individuals Covered159
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of commissions paid to insurance brokerUSD $17,795
Total amount of fees paid to insurance companyUSD $11,231
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $61,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,645
Amount paid for insurance broker fees3081
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
Insurance broker nameEMPLOYER PLAN SERVICES INC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5392904
Policy instance 1
Insurance contract or identification number5392904
Number of Individuals Covered142
Insurance policy start date2014-10-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,035
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,035
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5392904
Policy instance 1
Insurance contract or identification number5392904
Number of Individuals Covered142
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $3,251
Total amount of fees paid to insurance companyUSD $1,246
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,251
Amount paid for insurance broker fees1246
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5392904
Policy instance 2
Insurance contract or identification number5392904
Number of Individuals Covered142
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $3,251
Total amount of fees paid to insurance companyUSD $1,246
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 $73,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,251
Amount paid for insurance broker fees1246
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameJOHNSON AND BRYAN INC
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00605714
Policy instance 1
Insurance contract or identification number00605714
Number of Individuals Covered149
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $32,248
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $217,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,248
Insurance broker organization code?3
Insurance broker nameJOHNSON AND BRYAN

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