ADOBE DRYWALL, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ADOBE DRYWALL, LLC WRAP BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 153 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 153 |
| 2021: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 157 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 157 |
| 2020: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 149 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 153 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 153 |
| 2019: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 166 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 152 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 152 |
| 2018: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 164 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 164 |
| 2017: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 157 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 157 |
| 2016: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 150 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 150 |
| 2015: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 147 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 147 |
| 2014: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 166 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 166 |
| 2013: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 117 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 0 |
| Total of all active and inactive participants | 2013-07-01 | 117 |
| 2022: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Submission has been amended | No |
| 2021-07-01 | This submission is the final filing | No |
| 2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-07-01 | Plan is a collectively bargained plan | No |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Submission has been amended | No |
| 2017-07-01 | This submission is the final filing | No |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-07-01 | Plan is a collectively bargained plan | No |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ADOBE DRYWALL, LLC WRAP BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | First time form 5500 has been submitted | Yes |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $9,661 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,661 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $42,877 | | Total amount of fees paid to insurance company | USD $72,997 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,454,502 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,877 | | Amount paid for insurance broker fees | 72997 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT AND BONUS | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $9,098 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,098 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 282 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $33,758 | | Total amount of fees paid to insurance company | USD $70,927 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,364,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,758 | | Amount paid for insurance broker fees | 70927 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES AND BONUS | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $8,846 | | Total amount of fees paid to insurance company | USD $2,476 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,846 | | Amount paid for insurance broker fees | 2476 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $11,820 | | Total amount of fees paid to insurance company | USD $68,068 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,335,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,820 | | Amount paid for insurance broker fees | 68068 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES AND BONUS | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $9,624 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,624 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $34,218 | | Total amount of fees paid to insurance company | USD $52,949 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,212,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,218 | | Amount paid for insurance broker fees | 52949 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $23,570 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,570 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 417 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $42,069 | | Total amount of fees paid to insurance company | USD $57,713 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,213,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,069 | | Amount paid for insurance broker fees | 57713 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $21,853 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,853 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 401 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $40,872 | | Total amount of fees paid to insurance company | USD $52,514 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $1,113,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,872 | | Amount paid for insurance broker fees | 52514 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOCIATES, INC. |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $16,029 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $54,145 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,029 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 905330 |
| Policy instance | 1 |
| Insurance contract or identification number | 905330 | | Number of Individuals Covered | 351 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $14,506 | | Total amount of fees paid to insurance company | USD $58,252 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $879,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,506 | | Amount paid for insurance broker fees | 58252 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOCIATES, INC. |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $12,695 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $49,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,695 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY, INC. |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 0609262 |
| Policy instance | 1 |
| Insurance contract or identification number | 0609262 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $9,108 | | Total amount of fees paid to insurance company | USD $3,643 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,108 | | Amount paid for insurance broker fees | 3643 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOCIATES |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00405 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00405 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $10,262 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $40,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,262 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY, INC. |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 0609262 |
| Policy instance | 1 |
| Insurance contract or identification number | 0609262 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $7,172 | | Total amount of fees paid to insurance company | USD $2,869 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,939 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,172 | | Amount paid for insurance broker fees | 2869 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK GOULD & ASSOCIATES |
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