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ADA MOTORS BENEFIT PLAN 401k Plan overview

Plan NameADA MOTORS BENEFIT PLAN
Plan identification number 501

ADA MOTORS BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

ADA MOTORS, INC. has sponsored the creation of one or more 401k plans.

Company Name:ADA MOTORS, INC.
Employer identification number (EIN):911430800
NAIC Classification:441110
NAIC Description:New Car Dealers

Additional information about ADA MOTORS, INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 1988-12-20
Company Identification Number: 601142981
Legal Registered Office Address: 15025 1ST AVE S

SEATTLE
United States of America (USA)
981480000

More information about ADA MOTORS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADA MOTORS BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01TESSA MORRIS2023-02-17
5012020-10-01TESSA MORRIS2022-05-04
5012019-10-01TESSA MORRIS2021-01-28
5012018-10-01TESSA MORRIS2020-10-07
5012017-10-01TESSA MORRIS2020-10-07
5012016-10-01TESSA MORRIS2020-10-07
5012015-10-01TESSA MORRIS2020-10-07

Plan Statistics for ADA MOTORS BENEFIT PLAN

401k plan membership statisitcs for ADA MOTORS BENEFIT PLAN

Measure Date Value
2021: ADA MOTORS BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01121
Total number of active participants reported on line 7a of the Form 55002021-10-01134
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01134
Number of employers contributing to the scheme2021-10-010
2020: ADA MOTORS BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01114
Total number of active participants reported on line 7a of the Form 55002020-10-01121
Number of retired or separated participants receiving benefits2020-10-010
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01121
Number of employers contributing to the scheme2020-10-010
2019: ADA MOTORS BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-0191
Total number of active participants reported on line 7a of the Form 55002019-10-01114
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01114
Number of employers contributing to the scheme2019-10-010
2018: ADA MOTORS BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01115
Total number of active participants reported on line 7a of the Form 55002018-10-0191
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-0191
Number of employers contributing to the scheme2018-10-010
2017: ADA MOTORS BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01121
Total number of active participants reported on line 7a of the Form 55002017-10-01102
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01102
Number of employers contributing to the scheme2017-10-010
2016: ADA MOTORS BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01151
Total number of active participants reported on line 7a of the Form 55002016-10-01132
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01132
Number of employers contributing to the scheme2016-10-010
2015: ADA MOTORS BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01128
Total number of active participants reported on line 7a of the Form 55002015-10-01153
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01153
Number of employers contributing to the scheme2015-10-010

Form 5500 Responses for ADA MOTORS BENEFIT PLAN

2021: ADA MOTORS BENEFIT PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: ADA MOTORS BENEFIT PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – InsuranceYes
2019: ADA MOTORS BENEFIT PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: ADA MOTORS BENEFIT PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – General assets of the sponsorYes
2017: ADA MOTORS BENEFIT PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: ADA MOTORS BENEFIT PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: ADA MOTORS BENEFIT PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01First time form 5500 has been submittedYes
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BRNQ
Policy instance 3
Insurance contract or identification numberGLUG0BRNQ
Number of Individuals Covered134
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $8,248
Total amount of fees paid to insurance companyUSD $4,572
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS,ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $101,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,248
Amount paid for insurance broker fees4572
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )
Policy contract number2134700
Policy instance 2
Insurance contract or identification number2134700
Number of Individuals Covered20
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $5,107
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $109,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,107
Amount paid for insurance broker fees0
Insurance broker organization code?3
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number8780400
Policy instance 1
Insurance contract or identification number8780400
Number of Individuals Covered87
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $21,211
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $516,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,211
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0BRNQ
Policy instance 4
Insurance contract or identification numberGUDB0BRNQ
Number of Individuals Covered121
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $7,240
Total amount of fees paid to insurance companyUSD $1,168
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $89,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,240
Amount paid for insurance broker fees1168
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number8780400
Policy instance 1
Insurance contract or identification number8780400
Number of Individuals Covered77
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $20,838
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $439,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,838
Amount paid for insurance broker fees0
Insurance broker organization code?3
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )
Policy contract number2134700
Policy instance 2
Insurance contract or identification number2134700
Number of Individuals Covered18
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $4,770
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $-2,364,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,770
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3455854
Policy instance 3
Insurance contract or identification numberE3455854
Number of Individuals Covered50
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $16,002
Total amount of fees paid to insurance companyUSD $4,262
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $80,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,744
Amount paid for insurance broker fees1077
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3471000
Policy instance 4
Insurance contract or identification numberE3471000
Number of Individuals Covered50
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $10,685
Total amount of fees paid to insurance companyUSD $1,924
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $50,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,860
Amount paid for insurance broker fees917
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632373
Policy instance 3
Insurance contract or identification number632373
Number of Individuals Covered43
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $2,985
Total amount of fees paid to insurance companyUSD $398
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $18,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,985
Amount paid for insurance broker fees398
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632371
Policy instance 2
Insurance contract or identification number632371
Number of Individuals Covered28
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $1,605
Total amount of fees paid to insurance companyUSD $214
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,605
Amount paid for insurance broker fees214
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632372
Policy instance 1
Insurance contract or identification number632372
Number of Individuals Covered114
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $521
Total amount of fees paid to insurance companyUSD $104
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $4,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $521
Amount paid for insurance broker fees104
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632372
Policy instance 2
Insurance contract or identification number632372
Number of Individuals Covered152
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $5,248
Total amount of fees paid to insurance companyUSD $738
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $38,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,248
Amount paid for insurance broker fees738
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3471000
Policy instance 1
Insurance contract or identification numberE3471000
Number of Individuals Covered54
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $8,688
Total amount of fees paid to insurance companyUSD $773
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $44,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,871
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632372
Policy instance 4
Insurance contract or identification number632372
Number of Individuals Covered155
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $6,065
Total amount of fees paid to insurance companyUSD $851
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $42,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-039978
Policy instance 3
Insurance contract or identification number010-039978
Number of Individuals Covered140
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $3,412
Total amount of fees paid to insurance companyUSD $6,276
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $60,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4002696
Policy instance 1
Insurance contract or identification number4002696
Number of Individuals Covered131
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $41,189
Total amount of fees paid to insurance companyUSD $2,496
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $823,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3471000
Policy instance 2
Insurance contract or identification numberE3471000
Number of Individuals Covered56
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $13,408
Total amount of fees paid to insurance companyUSD $3,681
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $47,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number632372
Policy instance 4
Insurance contract or identification number632372
Number of Individuals Covered189
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $7,570
Total amount of fees paid to insurance companyUSD $273
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $46,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,811
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3471000
Policy instance 3
Insurance contract or identification numberE3471000
Number of Individuals Covered29
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $7,302
Total amount of fees paid to insurance companyUSD $934
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $26,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,675
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-039978
Policy instance 2
Insurance contract or identification number010-039978
Number of Individuals Covered281
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $4,603
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,386
Amount paid for insurance broker fees0
Insurance broker organization code?3
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4002696
Policy instance 1
Insurance contract or identification number4002696
Number of Individuals Covered153
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $19,880
Total amount of fees paid to insurance companyUSD $1,623
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $663,906
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,240
Amount paid for insurance broker fees1623
Additional information about fees paid to insurance brokerPREFFERED PRODUCER PROGRAM
Insurance broker organization code?3

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