QSR CHAMPS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan QSR CHAMPS, INC. WELFARE PLANS
401k plan membership statisitcs for QSR CHAMPS, INC. WELFARE PLANS
| Measure | Date | Value |
|---|
| 2022: QSR CHAMPS, INC. WELFARE PLANS 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 361 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 366 |
| Total of all active and inactive participants | 2022-01-01 | 366 |
| 2021: QSR CHAMPS, INC. WELFARE PLANS 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 346 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 361 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| 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 | 361 |
| 2020: QSR CHAMPS, INC. WELFARE PLANS 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-05-01 | 357 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 346 |
| Number of retired or separated participants receiving benefits | 2020-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-05-01 | 0 |
| Total of all active and inactive participants | 2020-05-01 | 346 |
| 2019: QSR CHAMPS, INC. WELFARE PLANS 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-05-01 | 328 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 357 |
| Total of all active and inactive participants | 2019-05-01 | 357 |
| Total participants | 2019-05-01 | 357 |
| 2018: QSR CHAMPS, INC. WELFARE PLANS 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 328 |
| Total of all active and inactive participants | 2018-05-01 | 328 |
| Total participants | 2018-05-01 | 328 |
| 2017: QSR CHAMPS, INC. WELFARE PLANS 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 284 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 271 |
| Total of all active and inactive participants | 2017-05-01 | 271 |
| Total participants | 2017-05-01 | 271 |
| 2016: QSR CHAMPS, INC. WELFARE PLANS 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 287 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 284 |
| Total of all active and inactive participants | 2016-05-01 | 284 |
| Total participants | 2016-05-01 | 284 |
| 2015: QSR CHAMPS, INC. WELFARE PLANS 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 276 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 287 |
| Total of all active and inactive participants | 2015-05-01 | 287 |
| Total participants | 2015-05-01 | 287 |
| 2014: QSR CHAMPS, INC. WELFARE PLANS 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 276 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 276 |
| Total of all active and inactive participants | 2014-05-01 | 276 |
| Total participants | 2014-05-01 | 276 |
| 2013: QSR CHAMPS, INC. WELFARE PLANS 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 252 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 276 |
| Total of all active and inactive participants | 2013-05-01 | 276 |
| Total participants | 2013-05-01 | 276 |
| 2012: QSR CHAMPS, INC. WELFARE PLANS 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 245 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 252 |
| Total of all active and inactive participants | 2012-05-01 | 252 |
| Total participants | 2012-05-01 | 252 |
| 2011: QSR CHAMPS, INC. WELFARE PLANS 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 245 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 245 |
| Number of retired or separated participants receiving benefits | 2011-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-05-01 | 0 |
| Total of all active and inactive participants | 2011-05-01 | 245 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-05-01 | 0 |
| Total participants | 2011-05-01 | 245 |
| 2022: QSR CHAMPS, INC. WELFARE PLANS 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: QSR CHAMPS, INC. WELFARE PLANS 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 |
| 2020: QSR CHAMPS, INC. WELFARE PLANS 2020 form 5500 responses |
|---|
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | Submission has been amended | No |
| 2020-05-01 | This submission is the final filing | No |
| 2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-05-01 | Plan is a collectively bargained plan | No |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: QSR CHAMPS, INC. WELFARE PLANS 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Submission has been amended | No |
| 2019-05-01 | This submission is the final filing | No |
| 2019-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-05-01 | Plan is a collectively bargained plan | No |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: QSR CHAMPS, INC. WELFARE PLANS 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Submission has been amended | No |
| 2018-05-01 | This submission is the final filing | No |
| 2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-05-01 | Plan is a collectively bargained plan | No |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: QSR CHAMPS, INC. WELFARE PLANS 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Submission has been amended | No |
| 2017-05-01 | This submission is the final filing | No |
| 2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-05-01 | Plan is a collectively bargained plan | No |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: QSR CHAMPS, INC. WELFARE PLANS 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Submission has been amended | No |
| 2016-05-01 | This submission is the final filing | No |
| 2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-05-01 | Plan is a collectively bargained plan | No |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: QSR CHAMPS, INC. WELFARE PLANS 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: QSR CHAMPS, INC. WELFARE PLANS 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: QSR CHAMPS, INC. WELFARE PLANS 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | First time form 5500 has been submitted | Yes |
| 2013-05-01 | Submission has been amended | No |
| 2013-05-01 | This submission is the final filing | No |
| 2013-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-05-01 | Plan is a collectively bargained plan | No |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: QSR CHAMPS, INC. WELFARE PLANS 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | First time form 5500 has been submitted | Yes |
| 2012-05-01 | Submission has been amended | No |
| 2012-05-01 | This submission is the final filing | No |
| 2012-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-05-01 | Plan is a collectively bargained plan | No |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: QSR CHAMPS, INC. WELFARE PLANS 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | First time form 5500 has been submitted | Yes |
| 2011-05-01 | Submission has been amended | No |
| 2011-05-01 | This submission is the final filing | No |
| 2011-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-05-01 | Plan is a collectively bargained plan | No |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,170 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,170 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 361 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,480 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,480 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,326 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,326 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $5,254 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,254 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $4,742 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,742 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $4,833 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,833 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTIANSEN INSURANCE GROUP, INC. |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $5,367 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,367 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTIANSEN INSURANCE GROUP INC. |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $4,530 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,530 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTIANSEN INSURANCE, INC. |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $4,666 | | 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 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,666 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTIANSEN INSURANCE, INC. |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $4,434 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,434 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTIANSEN INSURANCE, INC. |
|
| DELTA DENTAL OF PUERTO RICO, INC. (National Association of Insurance Commissioners NAIC id number: 47085 ) |
| Policy contract number | 0978 |
| Policy instance | 1 |
| Insurance contract or identification number | 0978 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $4,237 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
