BROULIM'S SUPER MARKET, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN
401k plan membership statisitcs for BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2015: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 293 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 293 |
| 2014: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 1,207 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 256 |
| Total of all active and inactive participants | 2014-04-01 | 256 |
| Total participants | 2014-04-01 | 256 |
| 2013: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 1,188 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 1,207 |
| Total of all active and inactive participants | 2013-04-01 | 1,207 |
| Total participants | 2013-04-01 | 1,207 |
| 2012: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 1,034 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 1,188 |
| Total of all active and inactive participants | 2012-04-01 | 1,188 |
| Total participants | 2012-04-01 | 1,188 |
| 2011: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-04-01 | 1,030 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-04-01 | 1,034 |
| Total of all active and inactive participants | 2011-04-01 | 1,034 |
| Total participants | 2011-04-01 | 1,034 |
| 2010: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-04-01 | 681 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-04-01 | 1,030 |
| Total of all active and inactive participants | 2010-04-01 | 1,030 |
| Total participants | 2010-04-01 | 1,030 |
| 2009: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-04-01 | 634 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-04-01 | 681 |
| Total of all active and inactive participants | 2009-04-01 | 681 |
| Total participants | 2009-04-01 | 681 |
| 2008: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-04-01 | 632 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-04-01 | 634 |
| Total of all active and inactive participants | 2008-04-01 | 634 |
| Total participants | 2008-04-01 | 634 |
| 2007: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-04-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-04-01 | 632 |
| Total of all active and inactive participants | 2007-04-01 | 632 |
| Total participants | 2007-04-01 | 632 |
| Measure | Date | Value |
|---|
| 2015 : BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2015 401k financial data |
|---|
| Total income from all sources (including contributions) | 2015-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Was this plan covered by a fidelity bond | 2015-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Did the plan have assets held for investment | 2015-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| 2015: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Submission has been amended | No |
| 2013-04-01 | This submission is the final filing | No |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-04-01 | Plan is a collectively bargained plan | No |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Submission has been amended | No |
| 2012-04-01 | This submission is the final filing | No |
| 2012-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-04-01 | Plan is a collectively bargained plan | No |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Submission has been amended | No |
| 2011-04-01 | This submission is the final filing | No |
| 2011-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-04-01 | Plan is a collectively bargained plan | No |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | Submission has been amended | No |
| 2010-04-01 | This submission is the final filing | No |
| 2010-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-04-01 | Plan is a collectively bargained plan | No |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | Submission has been amended | No |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-04-01 | Plan is a collectively bargained plan | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2008 form 5500 responses |
|---|
| 2008-04-01 | Type of plan entity | Single employer plan |
| 2008-04-01 | Submission has been amended | No |
| 2008-04-01 | This submission is the final filing | No |
| 2008-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-04-01 | Plan is a collectively bargained plan | No |
| 2008-04-01 | Plan funding arrangement – Insurance | Yes |
| 2008-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: BROULIM'S SUPERMARKET, INC. WELFARE LIFE INSURANCE PLAN 2007 form 5500 responses |
|---|
| 2007-04-01 | Type of plan entity | Single employer plan |
| 2007-04-01 | Submission has been amended | No |
| 2007-04-01 | This submission is the final filing | No |
| 2007-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-04-01 | Plan is a collectively bargained plan | No |
| 2007-04-01 | Plan funding arrangement – Insurance | Yes |
| 2007-04-01 | Plan benefit arrangement – Insurance | Yes |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 851076 |
| Policy instance | 1 |
| Insurance contract or identification number | 851076 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $4,486 | | Are there contracts with allocated funds for individual policies? | 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 $4,486 | | Insurance broker organization code? | 3 | | Insurance broker name | ROD FURNISS EMPLOYEE BENEFIT 1 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 851053 |
| Policy instance | 1 |
| Insurance contract or identification number | 851053 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,968 | | 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 | 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 $2,968 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | RODNEY FURNISS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 1207 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $10,946 | | 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 | Yes | | 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 $10,946 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 1188 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $12,265 | | 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 | Yes | | 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 $12,265 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 1034 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $10,660 | | 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 | 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 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 1030 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $10,685 | | 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 | 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 $10,685 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 681 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-03-31 | | Total amount of commissions paid to insurance broker | USD $5,527 | | 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 | 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 $5,527 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 634 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2009-03-31 | | Total amount of commissions paid to insurance broker | USD $5,220 | | Total amount of fees paid to insurance company | USD $885 | | 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 | 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 $5,220 | | Amount paid for insurance broker fees | 885 | | Additional information about fees paid to insurance broker | COMMISSIONS BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 856174G |
| Policy instance | 1 |
| Insurance contract or identification number | 856174G | | Number of Individuals Covered | 632 | | Insurance policy start date | 2007-04-01 | | Insurance policy end date | 2008-03-31 | | Total amount of commissions paid to insurance broker | USD $2,682 | | 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 | Yes | | 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 $2,682 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | RODNEY FURNISS |
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