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BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 401k Plan overview

Plan NameBURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN
Plan identification number 001

BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
  • Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

CREEK CAPITAL DENTAL HOLDINGS, LLC has sponsored the creation of one or more 401k plans.

Company Name:CREEK CAPITAL DENTAL HOLDINGS, LLC
Employer identification number (EIN):821668064
NAIC Classification:621210
NAIC Description:Offices of Dentists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0012021-01-01
0012020-01-01
0012019-01-01
0012018-01-01JEFF BURG2019-11-26
0012017-01-01JEFF BURG2018-10-11

Plan Statistics for BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN

401k plan membership statisitcs for BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN

Measure Date Value
2021: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01115
Total number of active participants reported on line 7a of the Form 55002021-01-010
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-010
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2021-01-010
Total participants2021-01-010
Number of participants with account balances2021-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2021-01-010
2020: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01120
Total number of active participants reported on line 7a of the Form 55002020-01-0179
Number of retired or separated participants receiving benefits2020-01-011
Number of other retired or separated participants entitled to future benefits2020-01-0136
Total of all active and inactive participants2020-01-01116
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2020-01-010
Total participants2020-01-01116
Number of participants with account balances2020-01-01101
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2020-01-010
2019: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01132
Total number of active participants reported on line 7a of the Form 55002019-01-0185
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-0135
Total of all active and inactive participants2019-01-01121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2019-01-010
Total participants2019-01-01121
Number of participants with account balances2019-01-0197
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2019-01-010

Financial Data on BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN

Measure Date Value
2021 : BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-09-30$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-09-30$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-09-30$11,251
Total income from all sources (including contributions)2021-09-30$519,281
Total loss/gain on sale of assets2021-09-30$0
Total of all expenses incurred2021-09-30$4,623,300
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-09-30$4,623,300
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-09-30$150,374
Value of total assets at end of year2021-09-30$0
Value of total assets at beginning of year2021-09-30$4,115,270
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-09-30$0
Total interest from all sources2021-09-30$0
Total dividends received (eg from common stock, registered investment company shares)2021-09-30$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-09-30Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan2021-09-30$0
Was this plan covered by a fidelity bond2021-09-30Yes
Value of fidelity bond cover2021-09-30$500,000
If this is an individual account plan, was there a blackout period2021-09-30No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2021-09-30$0
Were there any nonexempt tranactions with any party-in-interest2021-09-30No
Contributions received from participants2021-09-30$86,742
Income. Received or receivable in cash from other sources (including rollovers)2021-09-30$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2021-09-30$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2021-09-30$11,251
Total non interest bearing cash at end of year2021-09-30$0
Total non interest bearing cash at beginning of year2021-09-30$14,093
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-09-30No
Income. Non cash contributions2021-09-30$0
Value of net income/loss2021-09-30$-4,104,019
Value of net assets at end of year (total assets less liabilities)2021-09-30$0
Value of net assets at beginning of year (total assets less liabilities)2021-09-30$4,104,019
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2021-09-30No
Were any leases to which the plan was party in default or uncollectible2021-09-30No
Value of interest in registered invesment companies (eg mutual funds) at end of year2021-09-30$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2021-09-30$4,101,177
Net investment gain/loss from registered investment companies (e.g. mutual funds)2021-09-30$368,907
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-09-30No
Was there a failure to transmit to the plan any participant contributions2021-09-30No
Has the plan failed to provide any benefit when due under the plan2021-09-30No
Contributions received in cash from employer2021-09-30$63,632
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-09-30$4,623,300
Did the plan have assets held for investment2021-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-09-30Yes
Opinion of an independent qualified public accountant for this plan2021-09-30Unqualified
Accountancy firm name2021-09-30TRAVELLER AND COMPANY, LLC
Accountancy firm EIN2021-09-30870668060
2020 : BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$11,251
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$0
Total income from all sources (including contributions)2020-12-31$1,143,820
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$161,983
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$123,040
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$475,822
Value of total assets at end of year2020-12-31$4,115,270
Value of total assets at beginning of year2020-12-31$3,122,182
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$38,943
Total interest from all sources2020-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$500,000
If this is an individual account plan, was there a blackout period2020-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2020-12-31$0
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$289,066
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2020-12-31$11,251
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2020-12-31$0
Total non interest bearing cash at end of year2020-12-31$14,093
Total non interest bearing cash at beginning of year2020-12-31$2,400
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$981,837
Value of net assets at end of year (total assets less liabilities)2020-12-31$4,104,019
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$3,122,182
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Value of interest in pooled separate accounts at end of year2020-12-31$4,101,177
Value of interest in pooled separate accounts at beginning of year2020-12-31$3,119,782
Net investment gain/loss from pooled separate accounts2020-12-31$667,998
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$186,756
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$123,040
Contract administrator fees2020-12-31$38,943
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31TRAVELLER AND COMPANY, LLC
Accountancy firm EIN2020-12-31870668060
2019 : BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total income from all sources (including contributions)2019-12-31$1,001,713
Total income from all sources (including contributions)2019-12-31$1,001,713
Total loss/gain on sale of assets2019-12-31$0
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$86,530
Total of all expenses incurred2019-12-31$86,530
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$55,556
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$55,556
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$448,617
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$448,617
Value of total assets at end of year2019-12-31$3,122,182
Value of total assets at end of year2019-12-31$3,122,182
Value of total assets at beginning of year2019-12-31$2,206,999
Value of total assets at beginning of year2019-12-31$2,206,999
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$30,974
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$30,974
Total interest from all sources2019-12-31$0
Total interest from all sources2019-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31Yes
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$500,000
Value of fidelity bond cover2019-12-31$500,000
If this is an individual account plan, was there a blackout period2019-12-31No
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$279,206
Contributions received from participants2019-12-31$279,206
Income. Received or receivable in cash from other sources (including rollovers)2019-12-31$8,115
Income. Received or receivable in cash from other sources (including rollovers)2019-12-31$8,115
Total non interest bearing cash at end of year2019-12-31$2,400
Total non interest bearing cash at end of year2019-12-31$2,400
Total non interest bearing cash at beginning of year2019-12-31$2,400
Total non interest bearing cash at beginning of year2019-12-31$2,400
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$915,183
Value of net income/loss2019-12-31$915,183
Value of net assets at end of year (total assets less liabilities)2019-12-31$3,122,182
Value of net assets at end of year (total assets less liabilities)2019-12-31$3,122,182
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$2,206,999
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$2,206,999
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Value of interest in pooled separate accounts at end of year2019-12-31$3,119,782
Value of interest in pooled separate accounts at end of year2019-12-31$3,119,782
Value of interest in pooled separate accounts at beginning of year2019-12-31$2,204,599
Value of interest in pooled separate accounts at beginning of year2019-12-31$2,204,599
Net investment gain/loss from pooled separate accounts2019-12-31$553,096
Net investment gain/loss from pooled separate accounts2019-12-31$553,096
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$161,296
Contributions received in cash from employer2019-12-31$161,296
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2019-12-31$55,556
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2019-12-31$55,556
Contract administrator fees2019-12-31$30,974
Contract administrator fees2019-12-31$30,974
Did the plan have assets held for investment2019-12-31Yes
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31Yes
Opinion of an independent qualified public accountant for this plan2019-12-31Disclaimer
Opinion of an independent qualified public accountant for this plan2019-12-31Disclaimer
Accountancy firm name2019-12-31TRAVELLER AND COMPANY, LLC
Accountancy firm name2019-12-31TRAVELLER AND COMPANY, LLC
Accountancy firm EIN2019-12-31870668060
Accountancy firm EIN2019-12-31870668060

Form 5500 Responses for BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN

2021: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingYes
2021-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: BURG CHILDREN'S DENTISTRY & ORTHODONTICS 401K PROFIT SHARING PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number121979
Policy instance 1
Insurance contract or identification number121979
Number of Individuals Covered0
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $12,343
Total amount of fees paid to insurance companyUSD $10,394
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $12,343
Insurance broker organization code?3
Amount paid for insurance broker fees8849
Additional information about fees paid to insurance brokerTPA FEES
JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number121979
Policy instance 1
Insurance contract or identification number121979
Number of Individuals Covered105
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $12,597
Total amount of fees paid to insurance companyUSD $2,177
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $12,597
Insurance broker organization code?3
Amount paid for insurance broker fees1577
Additional information about fees paid to insurance brokerTPA COMPENSATION
JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number121979
Policy instance 1
Insurance contract or identification number121979
Number of Individuals Covered101
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $10,282
Total amount of fees paid to insurance companyUSD $1,512
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $10,282
Insurance broker organization code?3
Amount paid for insurance broker fees1287
Additional information about fees paid to insurance brokerTPA COMPENSATION

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