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SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 401k Plan overview

Plan NameSIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN
Plan identification number 526

SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)

401k Sponsoring company profile

SIMONA AMERICA INDUSTRIES LLC has sponsored the creation of one or more 401k plans.

Company Name:SIMONA AMERICA INDUSTRIES LLC
Employer identification number (EIN):832286197
NAIC Classification:326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5262022-01-01
5262021-01-01
5262020-01-01
5262019-01-01

Plan Statistics for SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN

401k plan membership statisitcs for SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN

Measure Date Value
2022: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2022 401k membership
Total participants, beginning-of-year2022-01-01116
Total number of active participants reported on line 7a of the Form 55002022-01-0176
Number of retired or separated participants receiving benefits2022-01-011
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-0177
2021: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2021 401k membership
Total participants, beginning-of-year2021-01-01105
Total number of active participants reported on line 7a of the Form 55002021-01-01131
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 participants2021-01-01131
2020: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2020 401k membership
Total participants, beginning-of-year2020-01-01113
Total number of active participants reported on line 7a of the Form 55002020-01-01104
Number of retired or separated participants receiving benefits2020-01-011
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01105
2019: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2019 401k membership
Total participants, beginning-of-year2019-01-01192
Total number of active participants reported on line 7a of the Form 55002019-01-01111
Number of retired or separated participants receiving benefits2019-01-012
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01113

Financial Data on SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN

Measure Date Value
2022 : SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$59,168
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$90,245
Total income from all sources (including contributions)2022-12-31$1,344,843
Total loss/gain on sale of assets2022-12-31$0
Total of all expenses incurred2022-12-31$1,186,032
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$1,074,111
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$1,344,371
Value of total assets at end of year2022-12-31$310,039
Value of total assets at beginning of year2022-12-31$182,305
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$111,921
Total interest from all sources2022-12-31$472
Total dividends received (eg from common stock, registered investment company shares)2022-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Administrative expenses professional fees incurred2022-12-31$70,129
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$200,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$267,675
Value of other receiveables (less allowance for doubtful accounts) at end of year2022-12-31$132,320
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2022-12-31$32,413
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$158,811
Value of net assets at end of year (total assets less liabilities)2022-12-31$250,871
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$92,060
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2022-12-31$177,719
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2022-12-31$149,892
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2022-12-31$149,892
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2022-12-31$472
Expenses. Payments to insurance carriers foe the provision of benefits2022-12-31$1,074,111
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$1,076,696
Contract administrator fees2022-12-31$41,792
Liabilities. Value of benefit claims payable at end of year2022-12-31$59,168
Liabilities. Value of benefit claims payable at beginning of year2022-12-31$90,245
Did the plan have assets held for investment2022-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31BOBER MARKEY FEDOROVICH
Accountancy firm EIN2022-12-31341523030
2021 : SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$90,245
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$55,454
Total income from all sources (including contributions)2021-12-31$1,247,342
Total loss/gain on sale of assets2021-12-31$0
Total of all expenses incurred2021-12-31$1,193,505
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$1,076,552
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$1,246,953
Value of total assets at end of year2021-12-31$182,305
Value of total assets at beginning of year2021-12-31$93,677
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$116,953
Total interest from all sources2021-12-31$389
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Administrative expenses professional fees incurred2021-12-31$76,827
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$500,000
If this is an individual account plan, was there a blackout period2021-12-31No
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$246,812
Value of other receiveables (less allowance for doubtful accounts) at end of year2021-12-31$32,413
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2021-12-31$2,454
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$53,837
Value of net assets at end of year (total assets less liabilities)2021-12-31$92,060
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$38,223
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2021-12-31$149,892
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2021-12-31$91,223
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2021-12-31$91,223
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2021-12-31$389
Expenses. Payments to insurance carriers foe the provision of benefits2021-12-31$1,076,552
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$1,000,141
Contract administrator fees2021-12-31$40,126
Liabilities. Value of benefit claims payable at end of year2021-12-31$90,245
Liabilities. Value of benefit claims payable at beginning of year2021-12-31$55,454
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31BOBER MARKEY FEDOROVICH
Accountancy firm EIN2021-12-31341523030
2020 : SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 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$55,454
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$72,895
Total income from all sources (including contributions)2020-12-31$1,209,248
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$1,183,345
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$1,067,507
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,208,810
Value of total assets at end of year2020-12-31$93,677
Value of total assets at beginning of year2020-12-31$85,215
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$115,838
Total interest from all sources2020-12-31$438
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
Administrative expenses professional fees incurred2020-12-31$72,278
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
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$244,938
Value of other receiveables (less allowance for doubtful accounts) at end of year2020-12-31$2,454
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2020-12-31$1,813
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$25,903
Value of net assets at end of year (total assets less liabilities)2020-12-31$38,223
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$12,320
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 bearing cash (including money market accounts and certificates of deposits) at end of year2020-12-31$91,223
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2020-12-31$83,402
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2020-12-31$83,402
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2020-12-31$438
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$1,067,507
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$963,872
Contract administrator fees2020-12-31$43,560
Liabilities. Value of benefit claims payable at end of year2020-12-31$55,454
Liabilities. Value of benefit claims payable at beginning of year2020-12-31$72,895
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 name2020-12-31BOBER MARKEY FEDOROVICH
Accountancy firm EIN2020-12-31341523030
2019 : SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 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$72,895
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$1,052,104
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$1,039,784
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$914,236
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$1,052,030
Value of total assets at end of year2019-12-31$85,215
Value of total assets at beginning of year2019-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$125,548
Total interest from all sources2019-12-31$74
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
Administrative expenses professional fees incurred2019-12-31$75,556
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$500,000
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
Contributions received from participants2019-12-31$206,333
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$1,813
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$0
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$12,320
Value of net assets at end of year (total assets less liabilities)2019-12-31$12,320
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$0
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 leases to which the plan was party in default or uncollectible2019-12-31No
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2019-12-31$83,402
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2019-12-31$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2019-12-31$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2019-12-31$74
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$914,236
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
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$845,697
Contract administrator fees2019-12-31$49,992
Liabilities. Value of benefit claims payable at end of year2019-12-31$72,895
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$0
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
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)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31BOBER MARKEY FEDOROVICH
Accountancy firm EIN2019-12-31341523030

Form 5500 Responses for SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN

2022: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 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 filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 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 funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: SIMONA AMERICA INDUSTRIES LLC GROUP MEDICAL PAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01First time form 5500 has been submittedYes
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 funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered77
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Welfare Benefit Premiums Paid to CarrierUSD $310,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered131
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Welfare Benefit Premiums Paid to CarrierUSD $269,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered104
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Welfare Benefit Premiums Paid to CarrierUSD $247,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EVEREST REINSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract numberVERIS
Policy instance 1
Insurance contract or identification numberVERIS
Number of Individuals Covered111
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
Welfare Benefit Premiums Paid to CarrierUSD $245,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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