401k Plan data: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN plan

BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN
Plan identification number	501

BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

BRAHMIN LEATHER WORKS, LLC has sponsored the creation of one or more 401k plans.

Company Name: BRAHMIN LEATHER WORKS, LLC

Employer identification number (EIN): 831837879

NAIC Classification: 448320
NAIC Description: Luggage and Leather Goods Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-10-01
501 2018-10-01

Plan Statistics for BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2019: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 83
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 81
Number of retired or separated participants receiving benefits 2019-10-01 2
Number of other retired or separated participants entitled to future benefits 2019-10-01 2
Total of all active and inactive participants 2019-10-01 85
Total participants 2019-10-01 85
2018: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-10-01 173
Total number of active participants reported on line 7a of the Form 5500 2018-10-01 178
Number of retired or separated participants receiving benefits 2018-10-01 2
Number of other retired or separated participants entitled to future benefits 2018-10-01 2
Total of all active and inactive participants 2018-10-01 182

Measure	Date	Value
2019: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	83
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	81
Number of retired or separated participants receiving benefits	2019-10-01	2
Number of other retired or separated participants entitled to future benefits	2019-10-01	2
Total of all active and inactive participants	2019-10-01	85
Total participants	2019-10-01	85
2018: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-10-01	173
Total number of active participants reported on line 7a of the Form 5500	2018-10-01	178
Number of retired or separated participants receiving benefits	2018-10-01	2
Number of other retired or separated participants entitled to future benefits	2018-10-01	2
Total of all active and inactive participants	2018-10-01	182

Form 5500 Responses for BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN

2019: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	Submission has been amended	No
2019-10-01	This submission is the final filing	No
2019-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-10-01	Plan is a collectively bargained plan	No
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes
2018: BRAHMIN LEATHER WORKS, LLC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-10-01	Type of plan entity	Single employer plan
2018-10-01	Submission has been amended	No
2018-10-01	This submission is the final filing	No
2018-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-10-01	Plan is a collectively bargained plan	No
2018-10-01	Plan funding arrangement – Insurance	Yes
2018-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

Policy instance

Number of Individuals Covered	54
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $779
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 $10,834
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $779

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

Policy instance

Number of Individuals Covered	79
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $5,724
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
Welfare Benefit Premiums Paid to Carrier	USD $57,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $5,235
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

Policy instance

Number of Individuals Covered	82
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $29,623
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	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
Welfare Benefit Premiums Paid to Carrier	USD $1,249,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $29,623
Amount paid for insurance broker fees	0

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

Policy instance

Number of Individuals Covered	172
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $3,055
Total amount of fees paid to insurance company	USD $15
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 $66,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,055
Amount paid for insurance broker fees	15
Insurance broker organization code?	3

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )

Policy contract number

DBL 252334

Policy instance

Insurance contract or identification number	DBL 252334
Number of Individuals Covered	6
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
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	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	NY PAID FAMILY LEAVE
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 $708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VPL 302616

Policy instance

Insurance contract or identification number	VPL 302616
Number of Individuals Covered	48
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $5,794
Total amount of fees paid to insurance company	USD $782
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	No
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
Welfare Benefit Premiums Paid to Carrier	USD $28,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,794
Amount paid for insurance broker fees	782
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VG 186668

Policy instance

Insurance contract or identification number	VG 186668
Number of Individuals Covered	35
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $1,560
Total amount of fees paid to insurance company	USD $445
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	SUPPLEMENTAL LIFE, DEPENDENT LIFE
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 $15,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,560
Amount paid for insurance broker fees	445
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

VAR 207632

Policy instance

Insurance contract or identification number	VAR 207632
Number of Individuals Covered	44
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $262
Total amount of fees paid to insurance company	USD $49
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL AD&D, DEPENDENT 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 $1,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $262
Amount paid for insurance broker fees	49
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 158253

Policy instance

Insurance contract or identification number	GL 158253
Number of Individuals Covered	161
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $1,907
Total amount of fees paid to insurance company	USD $409
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $12,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,907
Amount paid for insurance broker fees	409
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

4954493

Policy instance

Insurance contract or identification number	4954493
Number of Individuals Covered	84
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $27,679
Total amount of fees paid to insurance company	USD $890
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	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
Welfare Benefit Premiums Paid to Carrier	USD $1,097,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,679
Amount paid for insurance broker fees	890
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

G 165822

Policy instance

Insurance contract or identification number	G 165822
Number of Individuals Covered	161
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $697
Total amount of fees paid to insurance company	USD $1,502
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	No
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 $46,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $697
Amount paid for insurance broker fees	1502
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30078273

Policy instance

Insurance contract or identification number	30078273
Number of Individuals Covered	60
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $727
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 $9,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $727
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

917398

Policy instance

Insurance contract or identification number	917398
Number of Individuals Covered	86
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $4,849
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
Welfare Benefit Premiums Paid to Carrier	USD $48,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,849
Insurance broker organization code?	3

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Company Name:	BRAHMIN LEATHER WORKS, LLC
Employer identification number (EIN):	831837879
NAIC Classification:	448320
NAIC Description:	Luggage and Leather Goods Stores