CLEMENTS FOODS COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CLEMENTS FOODS COMPANY WRAP PLAN
| Measure | Date | Value |
|---|
| 2022: CLEMENTS FOODS COMPANY WRAP PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 188 |
| Number of retired or separated participants receiving benefits | 2022-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-02-01 | 0 |
| Total of all active and inactive participants | 2022-02-01 | 188 |
| 2021: CLEMENTS FOODS COMPANY WRAP PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 187 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-02-01 | 0 |
| Total of all active and inactive participants | 2021-02-01 | 187 |
| 2020: CLEMENTS FOODS COMPANY WRAP PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 206 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 0 |
| Total of all active and inactive participants | 2020-02-01 | 206 |
| 2019: CLEMENTS FOODS COMPANY WRAP PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 206 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 206 |
| 2018: CLEMENTS FOODS COMPANY WRAP PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 231 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 210 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Total of all active and inactive participants | 2018-02-01 | 210 |
| 2017: CLEMENTS FOODS COMPANY WRAP PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 230 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 232 |
| 2016: CLEMENTS FOODS COMPANY WRAP PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 235 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 235 |
| 2022: CLEMENTS FOODS COMPANY WRAP PLAN 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | No |
| 2022-02-01 | This submission is the final filing | No |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-02-01 | Plan is a collectively bargained plan | No |
| 2022-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: CLEMENTS FOODS COMPANY WRAP PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Submission has been amended | No |
| 2021-02-01 | This submission is the final filing | No |
| 2021-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-02-01 | Plan is a collectively bargained plan | No |
| 2021-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CLEMENTS FOODS COMPANY WRAP PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | No |
| 2020-02-01 | This submission is the final filing | No |
| 2020-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-02-01 | Plan is a collectively bargained plan | No |
| 2020-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CLEMENTS FOODS COMPANY WRAP PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CLEMENTS FOODS COMPANY WRAP PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CLEMENTS FOODS COMPANY WRAP PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CLEMENTS FOODS COMPANY WRAP PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | First time form 5500 has been submitted | Yes |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3240 |
| Policy instance | 3 |
| Insurance contract or identification number | 3240 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $4,549 | | Total amount of fees paid to insurance company | USD $0 | | 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 $4,549 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $1,141 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,141 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 1 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $403 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $8,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $403 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 1 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $438 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $8,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $438 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $1,183 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,183 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3240 |
| Policy instance | 3 |
| Insurance contract or identification number | 3240 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $4,811 | | 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 $4,811 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | AGENT COMMISSION | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | 5102 |
| Policy instance | 4 |
| Insurance contract or identification number | 5102 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | 5102 |
| Policy instance | 4 |
| Insurance contract or identification number | 5102 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $2,509 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,078 | | Commission paid to Insurance Broker | USD $2,509 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NA | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3240 |
| Policy instance | 3 |
| Insurance contract or identification number | 3240 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $4,898 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Commission paid to Insurance Broker | USD $4,898 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,144 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,337 | | Commission paid to Insurance Broker | USD $1,144 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NA | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 1 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $402 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $8,038 | | Commission paid to Insurance Broker | USD $402 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NA | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 4 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $302 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $302 | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | 5102-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 5102-00 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $2,715 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,612 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,715 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $1,167 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,167 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 0003240 |
| Policy instance | 1 |
| Insurance contract or identification number | 0003240 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $4,832 | | Total amount of fees paid to insurance company | USD $0 | | 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 $4,832 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 0003240 |
| Policy instance | 1 |
| Insurance contract or identification number | 0003240 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $4,997 | | Total amount of fees paid to insurance company | USD $0 | | 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 $4,997 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $1,152 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,152 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 3 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $239 | | Total amount of fees paid to insurance company | USD $83 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $239 | | Amount paid for insurance broker fees | 83 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 64324 |
| Policy instance | 3 |
| Insurance contract or identification number | 64324 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $246 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $246 | | Insurance broker organization code? | 3 | | Insurance broker name | INSERVICES LLC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30024572 |
| Policy instance | 2 |
| Insurance contract or identification number | 30024572 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,133 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,833 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,133 | | Insurance broker organization code? | 3 | | Insurance broker name | INSERVICES, LLC |
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| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 0003240 |
| Policy instance | 1 |
| Insurance contract or identification number | 0003240 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $4,924 | | Total amount of fees paid to insurance company | USD $0 | | 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 $4,924 | | Insurance broker organization code? | 3 | | Insurance broker name | INSERVICES LLC |
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