AJR TRUCKING, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AJR TRUCKING, INC. HEALTH AND WELFARE PLAN
401k plan membership statisitcs for AJR TRUCKING, INC. HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2021 : AJR TRUCKING, INC. HEALTH AND WELFARE PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
| Total transfer of assets to this plan | 2021-12-31 | $0 |
| Total transfer of assets from this plan | 2021-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $66,283 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $100,260 |
| Total income from all sources (including contributions) | 2021-12-31 | $566,806 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $706,972 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $603,546 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $566,806 |
| Value of total assets at end of year | 2021-12-31 | $36,222 |
| Value of total assets at beginning of year | 2021-12-31 | $210,365 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $103,426 |
| Total interest from all sources | 2021-12-31 | $0 |
| 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 year | 2021-12-31 | No |
| Administrative expenses professional fees incurred | 2021-12-31 | $14,805 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $50,000 |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $10,746 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2021-12-31 | $14,870 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $5,054 |
| Administrative expenses (other) incurred | 2021-12-31 | $29,186 |
| Liabilities. Value of operating payables at end of year | 2021-12-31 | $20,831 |
| Liabilities. Value of operating payables at beginning of year | 2021-12-31 | $48,325 |
| Total non interest bearing cash at end of year | 2021-12-31 | $-1,557 |
| Total non interest bearing cash at beginning of year | 2021-12-31 | $151 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $-140,166 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $-30,061 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $110,105 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $588,676 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $556,060 |
| Employer contributions (assets) at end of year | 2021-12-31 | $37,779 |
| Employer contributions (assets) at beginning of year | 2021-12-31 | $205,160 |
| Contract administrator fees | 2021-12-31 | $59,435 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $45,452 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $51,935 |
| Did the plan have assets held for investment | 2021-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | BAS PARTNERS LLC |
| Accountancy firm EIN | 2021-12-31 | 208779390 |
| 2020 : AJR TRUCKING, INC. HEALTH AND WELFARE PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $100,260 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $23,965 |
| Total income from all sources (including contributions) | 2020-12-31 | $1,121,064 |
| Total loss/gain on sale of assets | 2020-12-31 | $0 |
| Total of all expenses incurred | 2020-12-31 | $1,215,162 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $1,040,103 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $1,121,064 |
| Value of total assets at end of year | 2020-12-31 | $236,327 |
| Value of total assets at beginning of year | 2020-12-31 | $254,130 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $175,059 |
| Total interest from all sources | 2020-12-31 | $0 |
| 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 year | 2020-12-31 | No |
| Administrative expenses professional fees incurred | 2020-12-31 | $18,638 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $50,000 |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Contributions received from participants | 2020-12-31 | $4,822 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2020-12-31 | $23,866 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $334 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $938 |
| Administrative expenses (other) incurred | 2020-12-31 | $36,122 |
| Liabilities. Value of operating payables at end of year | 2020-12-31 | $48,325 |
| Liabilities. Value of operating payables at beginning of year | 2020-12-31 | $23,965 |
| Total non interest bearing cash at end of year | 2020-12-31 | $151 |
| Total non interest bearing cash at beginning of year | 2020-12-31 | $12,864 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $-94,098 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $136,067 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $230,165 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $1,016,237 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $1,116,242 |
| Employer contributions (assets) at end of year | 2020-12-31 | $235,842 |
| Employer contributions (assets) at beginning of year | 2020-12-31 | $240,328 |
| Contract administrator fees | 2020-12-31 | $120,299 |
| Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $51,935 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-12-31 | $0 |
| Did the plan have assets held for investment | 2020-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2020-12-31 | 410746749 |
| 2019 : AJR TRUCKING, INC. HEALTH AND WELFARE PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $23,965 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $23,965 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $52,231 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $52,231 |
| Total income from all sources (including contributions) | 2019-12-31 | $1,089,363 |
| Total income from all sources (including contributions) | 2019-12-31 | $1,089,363 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total of all expenses incurred | 2019-12-31 | $1,168,429 |
| Total of all expenses incurred | 2019-12-31 | $1,168,429 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $983,868 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $983,868 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $1,089,363 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $1,089,363 |
| Value of total assets at end of year | 2019-12-31 | $254,130 |
| Value of total assets at end of year | 2019-12-31 | $254,130 |
| Value of total assets at beginning of year | 2019-12-31 | $361,462 |
| Value of total assets at beginning of year | 2019-12-31 | $361,462 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $184,561 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $184,561 |
| Total interest from all sources | 2019-12-31 | $0 |
| Total interest from all sources | 2019-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| 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 year | 2019-12-31 | No |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Administrative expenses professional fees incurred | 2019-12-31 | $14,000 |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $50,000 |
| Value of fidelity bond cover | 2019-12-31 | $50,000 |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $8,940 |
| Contributions received from participants | 2019-12-31 | $8,940 |
| Participant contributions at end of year | 2019-12-31 | $0 |
| Participant contributions at end of year | 2019-12-31 | $0 |
| Participant contributions at beginning of year | 2019-12-31 | $96 |
| Participant contributions at beginning of year | 2019-12-31 | $96 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $49,403 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2019-12-31 | $49,403 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $938 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $938 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $572 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $572 |
| Administrative expenses (other) incurred | 2019-12-31 | $41,487 |
| Administrative expenses (other) incurred | 2019-12-31 | $41,487 |
| Liabilities. Value of operating payables at end of year | 2019-12-31 | $23,965 |
| Liabilities. Value of operating payables at end of year | 2019-12-31 | $23,965 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $48,075 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $48,075 |
| Total non interest bearing cash at end of year | 2019-12-31 | $12,864 |
| Total non interest bearing cash at end of year | 2019-12-31 | $12,864 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $90,061 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $90,061 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $-79,066 |
| Value of net income/loss | 2019-12-31 | $-79,066 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $230,165 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $230,165 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $309,231 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $309,231 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $934,465 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $934,465 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $1,080,423 |
| Contributions received in cash from employer | 2019-12-31 | $1,080,423 |
| Employer contributions (assets) at end of year | 2019-12-31 | $240,328 |
| Employer contributions (assets) at end of year | 2019-12-31 | $240,328 |
| Employer contributions (assets) at beginning of year | 2019-12-31 | $270,733 |
| Employer contributions (assets) at beginning of year | 2019-12-31 | $270,733 |
| Contract administrator fees | 2019-12-31 | $129,074 |
| Contract administrator fees | 2019-12-31 | $129,074 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $0 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $0 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $4,156 |
| Liabilities. Value of benefit claims payable at beginning of year | 2019-12-31 | $4,156 |
| Did the plan have assets held for investment | 2019-12-31 | No |
| Did the plan have assets held for investment | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Accountancy firm name | 2019-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm name | 2019-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2019-12-31 | 410746749 |
| Accountancy firm EIN | 2019-12-31 | 410746749 |
| 2018 : AJR TRUCKING, INC. HEALTH AND WELFARE PLAN 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $52,231 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $47,721 |
| Total income from all sources (including contributions) | 2018-12-31 | $1,150,041 |
| Total loss/gain on sale of assets | 2018-12-31 | $0 |
| Total of all expenses incurred | 2018-12-31 | $1,099,670 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $905,481 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $1,150,041 |
| Value of total assets at end of year | 2018-12-31 | $425,524 |
| Value of total assets at beginning of year | 2018-12-31 | $370,643 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $194,189 |
| Total interest from all sources | 2018-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Administrative expenses professional fees incurred | 2018-12-31 | $12,200 |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $50,000 |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Contributions received from participants | 2018-12-31 | $8,186 |
| Participant contributions at end of year | 2018-12-31 | $96 |
| Participant contributions at beginning of year | 2018-12-31 | $0 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2018-12-31 | $35,479 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $572 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $51,546 |
| Administrative expenses (other) incurred | 2018-12-31 | $47,015 |
| Liabilities. Value of operating payables at end of year | 2018-12-31 | $48,075 |
| Liabilities. Value of operating payables at beginning of year | 2018-12-31 | $47,453 |
| Total non interest bearing cash at end of year | 2018-12-31 | $90,061 |
| Total non interest bearing cash at beginning of year | 2018-12-31 | $69,351 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $50,371 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $373,293 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $322,922 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $870,002 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $1,141,855 |
| Employer contributions (assets) at end of year | 2018-12-31 | $334,795 |
| Employer contributions (assets) at beginning of year | 2018-12-31 | $249,746 |
| Contract administrator fees | 2018-12-31 | $134,974 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2018-12-31 | $4,156 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-12-31 | $268 |
| Did the plan have assets held for investment | 2018-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
| Accountancy firm name | 2018-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2018-12-31 | 410746749 |
| 2017 : AJR TRUCKING, INC. HEALTH AND WELFARE PLAN 2017 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $47,721 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $34,990 |
| Total income from all sources (including contributions) | 2017-12-31 | $984,797 |
| Total loss/gain on sale of assets | 2017-12-31 | $0 |
| Total of all expenses incurred | 2017-12-31 | $844,937 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $699,932 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $984,797 |
| Value of total assets at end of year | 2017-12-31 | $370,643 |
| Value of total assets at beginning of year | 2017-12-31 | $218,052 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $145,005 |
| Total interest from all sources | 2017-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Administrative expenses professional fees incurred | 2017-12-31 | $400 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $35,000 |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Contributions received from participants | 2017-12-31 | $1,974 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2017-12-31 | $4,403 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $51,546 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $92 |
| Administrative expenses (other) incurred | 2017-12-31 | $32,047 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $47,453 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $34,990 |
| Total non interest bearing cash at end of year | 2017-12-31 | $69,351 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $76,573 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $139,860 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $322,922 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $183,062 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $695,529 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $982,823 |
| Employer contributions (assets) at end of year | 2017-12-31 | $249,746 |
| Employer contributions (assets) at beginning of year | 2017-12-31 | $141,387 |
| Contract administrator fees | 2017-12-31 | $112,558 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-12-31 | No |
| Liabilities. Value of benefit claims payable at end of year | 2017-12-31 | $268 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $0 |
| Did the plan have assets held for investment | 2017-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2017-12-31 | 410746749 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 924735 |
| Policy instance | 1 |
| Insurance contract or identification number | 924735 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $44,865 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,644,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1857 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $44,865 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 309212 |
| Policy instance | 2 |
| Insurance contract or identification number | 309212 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $5,245 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | HOSPITAL INDEMNITY, ACCIDENT PROTECTION, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,425 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,245 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 924735 |
| Policy instance | 1 |
| Insurance contract or identification number | 924735 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $39,673 | | Total amount of fees paid to insurance company | USD $5,616 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,374,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,673 | | Amount paid for insurance broker fees | 5616 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 33360261 |
| Policy instance | 7 |
| Insurance contract or identification number | 33360261 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $9,964 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $334,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,964 | | Insurance broker organization code? | 5 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG188479 |
| Policy instance | 6 |
| Insurance contract or identification number | VG188479 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $206 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $206 | | Insurance broker organization code? | 5 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | LM-169 |
| Policy instance | 4 |
| Insurance contract or identification number | LM-169 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,410 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,410 | | Insurance broker organization code? | 5 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 11273-24 |
| Policy instance | 1 |
| Insurance contract or identification number | 11273-24 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $574 | | Total amount of fees paid to insurance company | USD $3,730 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $574 | | Amount paid for insurance broker fees | 3730 | | Additional information about fees paid to insurance broker | FEE SERVICE AGREEMENT | | Insurance broker organization code? | 5 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10304491001 |
| Policy instance | 3 |
| Insurance contract or identification number | 10304491001 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,143 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,143 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743756 |
| Policy instance | 8 |
| Insurance contract or identification number | 743756 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,477 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $217,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,477 | | Insurance broker organization code? | 5 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154989 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 154989 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,038 | | Total amount of fees paid to insurance company | USD $1,077 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,038 | | Amount paid for insurance broker fees | 1077 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 251972 |
| Policy instance | 5 |
| Insurance contract or identification number | 251972 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $78 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,512 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78 | | Insurance broker organization code? | 5 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206803 |
| Policy instance | 8 |
| Insurance contract or identification number | VAR 206803 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $199 | | Total amount of fees paid to insurance company | USD $221 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $199 | | Amount paid for insurance broker fees | 221 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 11273-24 |
| Policy instance | 7 |
| Insurance contract or identification number | 11273-24 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBAJR2 |
| Policy instance | 1 |
| Insurance contract or identification number | CLLMBAJR2 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $6,949 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $75,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,949 | | Insurance broker organization code? | 5 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743756 |
| Policy instance | 2 |
| Insurance contract or identification number | 743756 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,303 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $330,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,303 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 251972 |
| Policy instance | 3 |
| Insurance contract or identification number | 251972 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $17,230 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $553,028 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,230 | | Insurance broker organization code? | 5 |
|
| EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
| Policy contract number | CL VIS AJR 1 |
| Policy instance | 6 |
| Insurance contract or identification number | CL VIS AJR 1 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $114 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $114 | | Insurance broker organization code? | 5 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10304491001 |
| Policy instance | 9 |
| Insurance contract or identification number | 10304491001 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $19 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | LM-169 |
| Policy instance | 10 |
| Insurance contract or identification number | LM-169 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2020-09-30 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $523 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,050 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $523 | | Insurance broker organization code? | 3 |
|
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 1395871 |
| Policy instance | 8 |
| Insurance contract or identification number | 1395871 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 11273-24 |
| Policy instance | 7 |
| Insurance contract or identification number | 11273-24 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
| Policy contract number | CL VIS ABC 1 |
| Policy instance | 6 |
| Insurance contract or identification number | CL VIS ABC 1 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $108 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,312 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $108 | | Insurance broker organization code? | 5 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154989 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 154989 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $735 | | Total amount of fees paid to insurance company | USD $829 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $735 | | Amount paid for insurance broker fees | 829 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 33360261 |
| Policy instance | 3 |
| Insurance contract or identification number | 33360261 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $15,545 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $495,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,545 | | Insurance broker organization code? | 5 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743756 |
| Policy instance | 2 |
| Insurance contract or identification number | 743756 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $9,830 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $313,229 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,830 | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLLMBAJR3 |
| Policy instance | 1 |
| Insurance contract or identification number | CLLMBAJR3 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $14,696 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $54,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,696 | | Insurance broker organization code? | 5 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 33360262 |
| Policy instance | 5 |
| Insurance contract or identification number | 33360262 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $248 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $248 | | Insurance broker organization code? | 5 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743756 |
| Policy instance | 2 |
| Insurance contract or identification number | 743756 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $9,110 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $308,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,110 | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLL MB AJR1 |
| Policy instance | 1 |
| Insurance contract or identification number | CLL MB AJR1 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,250 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,250 | | Insurance broker organization code? | 5 |
|
| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FCE0-001 |
| Policy instance | 3 |
| Insurance contract or identification number | FCE0-001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206803 |
| Policy instance | 4 |
| Insurance contract or identification number | VAR 206803 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $269 | | Total amount of fees paid to insurance company | USD $259 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $269 | | Amount paid for insurance broker fees | 259 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154989 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 154989 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $880 | | Total amount of fees paid to insurance company | USD $848 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $880 | | Amount paid for insurance broker fees | 848 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 360261 |
| Policy instance | 6 |
| Insurance contract or identification number | 360261 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $24,086 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $480,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $24,086 | | Insurance broker organization code? | 5 |
|
| EYE MED VISION CARE (National Association of Insurance Commissioners NAIC id number: 98512 ) |
| Policy contract number | CLL MBA JR3 |
| Policy instance | 7 |
| Insurance contract or identification number | CLL MBA JR3 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $123 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $123 | | Insurance broker organization code? | 5 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 11273-24 |
| Policy instance | 8 |
| Insurance contract or identification number | 11273-24 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $164 | | Total amount of fees paid to insurance company | USD $887 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $164 | | Amount paid for insurance broker fees | 591 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 |
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| UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 359974 |
| Policy instance | 6 |
| Insurance contract or identification number | 359974 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,797 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $359,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,797 | | Insurance broker organization code? | 5 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLL MB AJR1 |
| Policy instance | 1 |
| Insurance contract or identification number | CLL MB AJR1 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 5 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 154989 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 154989 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $262 | | Total amount of fees paid to insurance company | USD $328 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,384 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $262 | | Amount paid for insurance broker fees | 328 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC |
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| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206803 |
| Policy instance | 4 |
| Insurance contract or identification number | VAR 206803 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $80 | | Total amount of fees paid to insurance company | USD $100 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $80 | | Amount paid for insurance broker fees | 100 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER SERVICE RELATED CONTRACT FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS INC |
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| MAGELLAN HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | FCE0-001 |
| Policy instance | 3 |
| Insurance contract or identification number | FCE0-001 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743756 |
| Policy instance | 2 |
| Insurance contract or identification number | 743756 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,200 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $273,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,200 | | Insurance broker organization code? | 5 | | Insurance broker name | FCE BENEFIT ADMINISTRATORS, INC. |
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