UWAJIMAYA, INC. has sponsored the creation of one or more 401k plans.
Additional information about UWAJIMAYA, INC.
Submission information for form 5500 for 401k plan UWAJIMAYA INC EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 375 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 117 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-03-01 | 0 |
| Total of all active and inactive participants | 2022-03-01 | 117 |
| Number of employers contributing to the scheme | 2022-03-01 | 0 |
| 2021: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 381 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 375 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 375 |
| Number of employers contributing to the scheme | 2021-03-01 | 0 |
| 2020: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 359 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 381 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 381 |
| Number of employers contributing to the scheme | 2020-03-01 | 0 |
| 2019: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 355 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 366 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 366 |
| Number of employers contributing to the scheme | 2019-03-01 | 0 |
| 2018: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 354 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 355 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 355 |
| Number of employers contributing to the scheme | 2018-03-01 | 0 |
| 2017: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 335 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 354 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 354 |
| 2016: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 321 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 335 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 335 |
| 2015: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 339 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 321 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 321 |
| 2014: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 341 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 339 |
| Total of all active and inactive participants | 2014-03-01 | 339 |
| Total participants | 2014-03-01 | 0 |
| 2013: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 322 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 341 |
| Total of all active and inactive participants | 2013-03-01 | 341 |
| Total participants | 2013-03-01 | 0 |
| 2012: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 327 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 322 |
| Total of all active and inactive participants | 2012-03-01 | 322 |
| Total participants | 2012-03-01 | 0 |
| 2011: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 327 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 327 |
| Total of all active and inactive participants | 2011-03-01 | 327 |
| Total participants | 2011-03-01 | 327 |
| 2009: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 281 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 318 |
| Total of all active and inactive participants | 2009-03-01 | 318 |
| Total participants | 2009-03-01 | 318 |
| 2022: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Single employer plan |
| 2022-03-01 | Plan funding arrangement – Insurance | Yes |
| 2022-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | Submission has been amended | No |
| 2016-03-01 | This submission is the final filing | No |
| 2016-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-03-01 | Plan is a collectively bargained plan | No |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | No |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | Plan funding arrangement – Insurance | Yes |
| 2012-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | Plan funding arrangement – Insurance | Yes |
| 2011-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: UWAJIMAYA INC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | Plan funding arrangement – Insurance | Yes |
| 2009-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA626 |
| Policy instance | 3 |
| Insurance contract or identification number | WA626 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $7,925 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,925 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7938939 |
| Policy instance | 2 |
| Insurance contract or identification number | E7938939 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $293 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $173 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017730-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-017730-00 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $19,006 | | Total amount of fees paid to insurance company | USD $714 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $126,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $19,006 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GROUP SUPPLEMENTAL COMMISSIONS |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA626 |
| Policy instance | 3 |
| Insurance contract or identification number | WA626 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $7,338 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,338 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7938939 |
| Policy instance | 2 |
| Insurance contract or identification number | E7938939 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $295 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,255 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $161 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017730-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-017730-00 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $15,312 | | Total amount of fees paid to insurance company | USD $2,773 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $102,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,312 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GROUP SUPPLEMENTAL COMMISSIONS |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA626 |
| Policy instance | 3 |
| Insurance contract or identification number | WA626 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $6,291 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,291 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7938939 |
| Policy instance | 2 |
| Insurance contract or identification number | E7938939 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017730-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-017730-00 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $15,955 | | Total amount of fees paid to insurance company | USD $3,187 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $106,363 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,955 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GROUP SUPPLEMENTAL COMMISSIONS |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA626 |
| Policy instance | 3 |
| Insurance contract or identification number | WA626 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $5,620 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,620 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7938939 |
| Policy instance | 2 |
| Insurance contract or identification number | E7938939 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $697 | | Total amount of fees paid to insurance company | USD $335 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Amount paid for insurance broker fees | 285 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017730-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 01-017730-00 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $13,576 | | Total amount of fees paid to insurance company | USD $1,688 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $90,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,576 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GROUP SUPPLEMENTAL COMMISSIONS |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7938939 |
| Policy instance | 2 |
| Insurance contract or identification number | E7938939 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $435 | | Total amount of fees paid to insurance company | USD $3 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $249 | | Amount paid for insurance broker fees | 2 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD TERRY GOTHAM |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 222208 |
| Policy instance | 1 |
| Insurance contract or identification number | 222208 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $11,940 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $79,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,940 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
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