401k Plan data: AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN plan

AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN 401k Plan overview

Plan Name	AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN
Plan identification number	501

AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

AFFIRMATIVE INSURANCE HOLDINGS, INC has sponsored the creation of one or more 401k plans.

Company Name: AFFIRMATIVE INSURANCE HOLDINGS, INC

Employer identification number (EIN): 752770432

NAIC Classification: 524290

Additional information about AFFIRMATIVE INSURANCE HOLDINGS, INC

Jurisdiction of Incorporation: State of Delaware Division of Corporations

Incorporation Date:

Company Identification Number: 2913512

More information about AFFIRMATIVE INSURANCE HOLDINGS, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-01-01 KIMBERLY DOMINGUEZ KIMBERLY DOMINGUEZ 2015-04-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2014-01-01	KIMBERLY DOMINGUEZ		KIMBERLY DOMINGUEZ	2015-04-29

Plan Statistics for AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN

401k plan membership statisitcs for AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN

Measure Date Value
2014: AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 880
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 369
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 369

Measure	Date	Value
2014: AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	880
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	369
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	369

Form 5500 Responses for AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN

2014: AFFIRMATIVE INSURANCE HOLDINGS, INC WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

19822

Policy instance

Insurance contract or identification number	19822
Number of Individuals Covered	781
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $15,996
Total amount of fees paid to insurance company	USD $9,060
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	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,996
Amount paid for insurance broker fees	9060
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	THE PLEXUS GROUPE LLC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

148384

Policy instance

Insurance contract or identification number	148384
Number of Individuals Covered	477
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,729
Total amount of fees paid to insurance company	USD $2,905
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	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
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 $9,729
Amount paid for insurance broker fees	2905
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION
Insurance broker organization code?	3
Insurance broker name	THE PLEXUS GROUPE LLC

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

SSLIHCRS0045614

Policy instance

Insurance contract or identification number	SSLIHCRS0045614
Number of Individuals Covered	366
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $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 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	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 $56,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	AFFIRMATIVE INSURANCE HOLDINGS, INC
Employer identification number (EIN):	752770432
NAIC Classification:	524290

Jurisdiction of Incorporation:	State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number:	2913512