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Filing

Pomfret School Incorporated Welfare Wrap Benefits Plan

Pomfret School Incorporated • EIN 06-0646784 • Pomfret, CT • Plan year 2017

Company ProfileSource Archive

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398 Pomfret SteetPomfret, CT 06258
Filing Insights

Participants

Up

134 → 136

2 • 1.49%

Assets

No comparison

- → -

No earlier value available.

Investment Management Fee

-

Admin expenses - • Total expenses -

Filing Details

Context

No event flags were generated for this filing.

Status Flags

Fidelity bond in place

Not reported

Limited-scope audit performed

Not reported

Contributions transmitted on time

Not reported

Participant loans in default

Not reported

Leases in default

Not reported

Reportable party-in-interest issues

Not reported

Loss discovered during year

Not reported

Assets with undetermined value

Not reported

Non-cash contributions

Not reported

Assets held for investment

Not reported

5% transactions reported

Not reported

All plan assets distributed

Not reported

Benefits paid when due

Not reported

Plan blackout period

Not reported

Plan termination resolution adopted

Not reported

Counterparties
Known direct compensation$399,999
ProviderServicesLocationDirect CompensationRelated
CONNECTICAREEIN 06-1618303Appraisal-$373,874-
SCHUSTER DRICOLL, LLCService provider-$26,125-

Company Timeline

This filing is highlighted inside the broader sponsor history.

Year / FilingFilingsParticipantsAssetsContributionsContrib./Participant
20242180$48,310,334$1,820,785$10,115iApproximate average salary by contribution assumption: employee only about $252,887 at 4% or $168,591 at 6%; with 50% employer match about $168,591 at 4% or $112,394 at 6%; with 100% employer match about $126,443 at 4% or $84,296 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-180$48,310,334$1,820,785$10,115iApproximate average salary by contribution assumption: employee only about $252,887 at 4% or $168,591 at 6%; with 50% employer match about $168,591 at 4% or $112,394 at 6%; with 100% employer match about $126,443 at 4% or $84,296 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-88---
20232168$43,635,342$1,718,755$10,231iApproximate average salary by contribution assumption: employee only about $255,767 at 4% or $170,511 at 6%; with 50% employer match about $170,511 at 4% or $113,674 at 6%; with 100% employer match about $127,884 at 4% or $85,256 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-168$43,635,342$1,718,755$10,231iApproximate average salary by contribution assumption: employee only about $255,767 at 4% or $170,511 at 6%; with 50% employer match about $170,511 at 4% or $113,674 at 6%; with 100% employer match about $127,884 at 4% or $85,256 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-134---
20222160$37,643,800$1,859,453$11,622iApproximate average salary by contribution assumption: employee only about $290,540 at 4% or $193,693 at 6%; with 50% employer match about $193,693 at 4% or $129,129 at 6%; with 100% employer match about $145,270 at 4% or $96,847 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-160$37,643,800$1,859,453$11,622iApproximate average salary by contribution assumption: employee only about $290,540 at 4% or $193,693 at 6%; with 50% employer match about $193,693 at 4% or $129,129 at 6%; with 100% employer match about $145,270 at 4% or $96,847 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20212167$44,308,118$1,586,176$9,498iApproximate average salary by contribution assumption: employee only about $237,451 at 4% or $158,301 at 6%; with 50% employer match about $158,301 at 4% or $105,534 at 6%; with 100% employer match about $118,726 at 4% or $79,150 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-167$44,308,118$1,586,176$9,498iApproximate average salary by contribution assumption: employee only about $237,451 at 4% or $158,301 at 6%; with 50% employer match about $158,301 at 4% or $105,534 at 6%; with 100% employer match about $118,726 at 4% or $79,150 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20202159$40,130,910$1,793,943$11,283iApproximate average salary by contribution assumption: employee only about $282,067 at 4% or $188,044 at 6%; with 50% employer match about $188,044 at 4% or $125,363 at 6%; with 100% employer match about $141,033 at 4% or $94,022 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-159$40,130,910$1,793,943$11,283iApproximate average salary by contribution assumption: employee only about $282,067 at 4% or $188,044 at 6%; with 50% employer match about $188,044 at 4% or $125,363 at 6%; with 100% employer match about $141,033 at 4% or $94,022 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20192170$35,325,112$1,585,064$9,324iApproximate average salary by contribution assumption: employee only about $233,098 at 4% or $155,398 at 6%; with 50% employer match about $155,398 at 4% or $103,599 at 6%; with 100% employer match about $116,549 at 4% or $77,699 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-170$35,325,112$1,585,064$9,324iApproximate average salary by contribution assumption: employee only about $233,098 at 4% or $155,398 at 6%; with 50% employer match about $155,398 at 4% or $103,599 at 6%; with 100% employer match about $116,549 at 4% or $77,699 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20182169$29,933,802$1,517,084$8,977iApproximate average salary by contribution assumption: employee only about $224,421 at 4% or $149,614 at 6%; with 50% employer match about $149,614 at 4% or $99,743 at 6%; with 100% employer match about $112,210 at 4% or $74,807 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-169$29,933,802$1,517,084$8,977iApproximate average salary by contribution assumption: employee only about $224,421 at 4% or $149,614 at 6%; with 50% employer match about $149,614 at 4% or $99,743 at 6%; with 100% employer match about $112,210 at 4% or $74,807 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20172179$32,877,831$1,416,788$7,915iApproximate average salary by contribution assumption: employee only about $197,875 at 4% or $131,917 at 6%; with 50% employer match about $131,917 at 4% or $87,945 at 6%; with 100% employer match about $98,938 at 4% or $65,958 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-179$32,877,831$1,416,788$7,915iApproximate average salary by contribution assumption: employee only about $197,875 at 4% or $131,917 at 6%; with 50% employer match about $131,917 at 4% or $87,945 at 6%; with 100% employer match about $98,938 at 4% or $65,958 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits PlanCurrent136---
20162170$28,336,344$1,499,397$8,820iApproximate average salary by contribution assumption: employee only about $220,500 at 4% or $147,000 at 6%; with 50% employer match about $147,000 at 4% or $98,000 at 6%; with 100% employer match about $110,250 at 4% or $73,500 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-170$28,336,344$1,499,397$8,820iApproximate average salary by contribution assumption: employee only about $220,500 at 4% or $147,000 at 6%; with 50% employer match about $147,000 at 4% or $98,000 at 6%; with 100% employer match about $110,250 at 4% or $73,500 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-134---
20152186$26,951,522$1,199,544$6,449iApproximate average salary by contribution assumption: employee only about $161,229 at 4% or $107,486 at 6%; with 50% employer match about $107,486 at 4% or $71,657 at 6%; with 100% employer match about $80,615 at 4% or $53,743 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-186$26,951,522$1,199,544$6,449iApproximate average salary by contribution assumption: employee only about $161,229 at 4% or $107,486 at 6%; with 50% employer match about $107,486 at 4% or $71,657 at 6%; with 100% employer match about $80,615 at 4% or $53,743 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20142212$27,002,738$1,188,194$5,605iApproximate average salary by contribution assumption: employee only about $140,117 at 4% or $93,411 at 6%; with 50% employer match about $93,411 at 4% or $62,274 at 6%; with 100% employer match about $70,059 at 4% or $46,706 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-212$27,002,738$1,188,194$5,605iApproximate average salary by contribution assumption: employee only about $140,117 at 4% or $93,411 at 6%; with 50% employer match about $93,411 at 4% or $62,274 at 6%; with 100% employer match about $70,059 at 4% or $46,706 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-136---
20132222$26,308,759$1,138,700$5,129iApproximate average salary by contribution assumption: employee only about $128,232 at 4% or $85,488 at 6%; with 50% employer match about $85,488 at 4% or $56,992 at 6%; with 100% employer match about $64,116 at 4% or $42,744 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-222$26,308,759$1,138,700$5,129iApproximate average salary by contribution assumption: employee only about $128,232 at 4% or $85,488 at 6%; with 50% employer match about $85,488 at 4% or $56,992 at 6%; with 100% employer match about $64,116 at 4% or $42,744 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-138---
20122203$21,937,516$1,118,656$5,511iApproximate average salary by contribution assumption: employee only about $137,766 at 4% or $91,844 at 6%; with 50% employer match about $91,844 at 4% or $61,229 at 6%; with 100% employer match about $68,883 at 4% or $45,922 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-203$21,937,516$1,118,656$5,511iApproximate average salary by contribution assumption: employee only about $137,766 at 4% or $91,844 at 6%; with 50% employer match about $91,844 at 4% or $61,229 at 6%; with 100% employer match about $68,883 at 4% or $45,922 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-137---
20112191$19,288,153$1,006,299$5,269iApproximate average salary by contribution assumption: employee only about $131,715 at 4% or $87,810 at 6%; with 50% employer match about $87,810 at 4% or $58,540 at 6%; with 100% employer match about $65,857 at 4% or $43,905 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-191$19,288,153$1,006,299$5,269iApproximate average salary by contribution assumption: employee only about $131,715 at 4% or $87,810 at 6%; with 50% employer match about $87,810 at 4% or $58,540 at 6%; with 100% employer match about $65,857 at 4% or $43,905 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-135---
20102200$18,619,840$916,222$4,581iApproximate average salary by contribution assumption: employee only about $114,528 at 4% or $76,352 at 6%; with 50% employer match about $76,352 at 4% or $50,901 at 6%; with 100% employer match about $57,264 at 4% or $38,176 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-200$18,619,840$916,222$4,581iApproximate average salary by contribution assumption: employee only about $114,528 at 4% or $76,352 at 6%; with 50% employer match about $76,352 at 4% or $50,901 at 6%; with 100% employer match about $57,264 at 4% or $38,176 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-132---
20092188$16,888,569$839,604$4,466iApproximate average salary by contribution assumption: employee only about $111,649 at 4% or $74,433 at 6%; with 50% employer match about $74,433 at 4% or $49,622 at 6%; with 100% employer match about $55,825 at 4% or $37,216 at 6%.
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-188$16,888,569$839,604$4,466iApproximate average salary by contribution assumption: employee only about $111,649 at 4% or $74,433 at 6%; with 50% employer match about $74,433 at 4% or $49,622 at 6%; with 100% employer match about $55,825 at 4% or $37,216 at 6%.
Pomfret School Incorporated Welfare Wrap Benefits Plan-131---
20085113$0$0-
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-0---
Pomfret School Incorporated Long Term Disability Insurance Plan-0---
Pomfret School Incorporated Welfare Wrap Benefits Plan-113---
20075137$0$0-
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-137---
Pomfret School Incorporated Long Term Disability Insurance Plan-137---
Pomfret School Incorporated Welfare Wrap Benefits Plan-104---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
20065135$0$0-
Pomfret School Incorporated Long Term Disability Insurance Plan-135---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-135---
Pomfret School Incorporated Welfare Wrap Benefits Plan-101---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
20055135$0$0-
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-135---
Pomfret School Incorporated Long Term Disability Insurance Plan-135---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Welfare Wrap Benefits Plan-100---
20045130$0$0-
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-130---
Pomfret School Incorporated Long Term Disability Insurance Plan-130---
Pomfret School Incorporated Welfare Wrap Benefits Plan-99---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
20035123$0$0-
Pomfret School Incorporated Long Term Disability Insurance Plan-123---
Pomfret School Incorporated Welfare Wrap Benefits Plan-98---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-123---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
20025130$0$0-
Pomfret School Incorporated Welfare Wrap Benefits Plan-96---
Pomfret School Incorporated Long Term Disability Insurance Plan-130---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-130---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
20015119$0$0-
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-119---
Pomfret School Incorporated Welfare Wrap Benefits Plan-91---
Pomfret School Incorporated Long Term Disability Insurance Plan-119---
20004112$0$0-
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-112---
Pomfret School Incorporated Long Term Disability Insurance Plan-0---
199940$0$0-
Pomfret School Incorporated Tiaa-Cref 403B Defined Contribution Plan-0---
Pomfret School Incorporated Tiaa-Cref Tax-Deferred Annuity Plan for All Employees-0---
Pomfret School Incorporated Long Term Disability Insurance Plan-0---
Pomfret School Incorporated Life Insurance and Ad&D Insurance Plan-0---
Schedule Details

Schedule A

Row 1
Form Id
4
Ins Broker Name
SCHUSTER DRISCOLL, LLC
Ins Broker US Address1
135 SOUTH ROAD
Ins Broker US City
FARMINGTON
Ins Broker US State
CT
Ins Broker US ZIP
06032
Ins Broker Comm Pd Amount
$3,347
Ins Broker Fees Pd Amount
$0
Ins Broker Code
3
Row 2
Form Id
1
Ins Broker Name
SCHUSTER DRISCOLL, LLC
Ins Broker US Address1
135 SOUTH ROAD
Ins Broker US City
FARMINGTON
Ins Broker US State
CT
Ins Broker US ZIP
06032
Ins Broker Comm Pd Amount
$530
Ins Broker Fees Pd Amount
$148
Ins Broker Fees Pd Text
BROKER BONUS
Ins Broker Code
3
Row 3
Form Id
2
Ins Broker Name
SCHUSTER DRISCOLL, LLC
Ins Broker US Address1
135 SOUTH ROAD
Ins Broker US City
FARMINGTON
Ins Broker US State
CT
Ins Broker US ZIP
06032
Ins Broker Comm Pd Amount
$2,453
Ins Broker Fees Pd Amount
$480
Ins Broker Fees Pd Text
BROKER BONUS
Ins Broker Code
3
Row 4
Form Id
3
Ins Broker Name
SCHUSTER DRISCOLL, LLC
Ins Broker US Address1
135 SOUTH ROAD
Ins Broker US City
FARMINGTON
Ins Broker US State
CT
Ins Broker US ZIP
06032
Ins Broker Comm Pd Amount
$1,527
Ins Broker Fees Pd Amount
$394
Ins Broker Fees Pd Text
BROKER BONUS
Ins Broker Code
3
Row 5
Ins Carrier Name: NATIONWIDE LIFE INSURANCE COMPANY
Form Id
5
Schedule A Plan Year Begin Date
2017-07-01
Schedule A Plan Year End Date
2018-06-30
Schedule A Plan Num
511
Schedule A EIN
06-0646784
Ins Carrier Name
NATIONWIDE LIFE INSURANCE COMPANY
Ins Carrier EIN
31-4156830
Ins Carrier Naic Code
66869
Ins Contract Num
17NW02J565
Ins Prsn Covered End of year Count
95
Ins Policy From Date
2017-07-01
Ins Policy To Date
2018-06-30
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Alloc Contracts Indiv Indicator
No
Alloc Contracts Group Indicator
No
Alloc Contracts Other Indicator
No
Pens Distr Bnft Terminate Pln Indicator
No
Unalloc Contracts Dep Adm Indicator
No
Unal Contrac Imm Part Guar Indicator
No
Unal Contracts Guar Invest Indicator
No
Unalloc Contracts Other Indicator
No
Wlfr Bnft Health Indicator
No
Wlfr Bnft Dental Indicator
No
Wlfr Bnft Vision Indicator
No
Wlfr Bnft Life Insur Indicator
No
Wlfr Bnft Temp Disab Indicator
No
Wlfr Bnft Long Terminate Disab Indicator
No
Wlfr Bnft Unemp Indicator
No
Wlfr Bnft Drug Indicator
No
Wlfr Bnft Stop Loss Indicator
Yes
Wlfr Bnft Hmo Indicator
No
Wlfr Bnft Ppo Indicator
No
Wlfr Bnft Indemnity Indicator
No
Wlfr Bnft Other Indicator
No
Wlfr Refund Cash Indicator
No
Wlfr Refund Credit Indicator
No
Wlfr Total Charges Paid Amount
$321,995
Ins Fail Provide Info Indicator
No
Row 6
Ins Carrier Name: THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Form Id
1
Schedule A Plan Year Begin Date
2017-07-01
Schedule A Plan Year End Date
2018-06-30
Schedule A Plan Num
511
Schedule A EIN
06-0646784
Ins Carrier Name
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Ins Carrier EIN
35-0472300
Ins Carrier Naic Code
65676
Ins Contract Num
40000100019982
Ins Prsn Covered End of year Count
63
Ins Policy From Date
2017-07-01
Ins Policy To Date
2018-06-30
Ins Broker Comm Total Amount
$530
Ins Broker Fees Total Amount
$148
Alloc Contracts Indiv Indicator
No
Alloc Contracts Group Indicator
No
Alloc Contracts Other Indicator
No
Pens Distr Bnft Terminate Pln Indicator
No
Unalloc Contracts Dep Adm Indicator
No
Unal Contrac Imm Part Guar Indicator
No
Unal Contracts Guar Invest Indicator
No
Unalloc Contracts Other Indicator
No
Wlfr Bnft Health Indicator
No
Wlfr Bnft Dental Indicator
No
Wlfr Bnft Vision Indicator
No
Wlfr Bnft Life Insur Indicator
Yes
Wlfr Bnft Temp Disab Indicator
No
Wlfr Bnft Long Terminate Disab Indicator
No
Wlfr Bnft Unemp Indicator
No
Wlfr Bnft Drug Indicator
No
Wlfr Bnft Stop Loss Indicator
No
Wlfr Bnft Hmo Indicator
No
Wlfr Bnft Ppo Indicator
No
Wlfr Bnft Indemnity Indicator
No
Wlfr Bnft Other Indicator
No
Wlfr Refund Cash Indicator
No
Wlfr Refund Credit Indicator
No
Wlfr Total Charges Paid Amount
$5,296
Ins Fail Provide Info Indicator
No
Row 7
Ins Carrier Name: THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Form Id
2
Schedule A Plan Year Begin Date
2017-07-01
Schedule A Plan Year End Date
2018-06-30
Schedule A Plan Num
511
Schedule A EIN
06-0646784
Ins Carrier Name
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Ins Carrier EIN
35-0472300
Ins Carrier Naic Code
65676
Ins Contract Num
10205902
Ins Prsn Covered End of year Count
135
Ins Policy From Date
2017-07-01
Ins Policy To Date
2018-06-30
Ins Broker Comm Total Amount
$2,453
Ins Broker Fees Total Amount
$480
Alloc Contracts Indiv Indicator
No
Alloc Contracts Group Indicator
No
Alloc Contracts Other Indicator
No
Pens Distr Bnft Terminate Pln Indicator
No
Unalloc Contracts Dep Adm Indicator
No
Unal Contrac Imm Part Guar Indicator
No
Unal Contracts Guar Invest Indicator
No
Unalloc Contracts Other Indicator
No
Wlfr Bnft Health Indicator
No
Wlfr Bnft Dental Indicator
No
Wlfr Bnft Vision Indicator
No
Wlfr Bnft Life Insur Indicator
No
Wlfr Bnft Temp Disab Indicator
No
Wlfr Bnft Long Terminate Disab Indicator
Yes
Wlfr Bnft Unemp Indicator
No
Wlfr Bnft Drug Indicator
No
Wlfr Bnft Stop Loss Indicator
No
Wlfr Bnft Hmo Indicator
No
Wlfr Bnft Ppo Indicator
No
Wlfr Bnft Indemnity Indicator
No
Wlfr Bnft Other Indicator
No
Wlfr Refund Cash Indicator
No
Wlfr Refund Credit Indicator
No
Wlfr Total Charges Paid Amount
$17,035
Ins Fail Provide Info Indicator
No
Row 8
Ins Carrier Name: THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Form Id
3
Schedule A Plan Year Begin Date
2017-07-01
Schedule A Plan Year End Date
2018-06-30
Schedule A Plan Num
511
Schedule A EIN
06-0646784
Ins Carrier Name
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY
Ins Carrier EIN
35-0472300
Ins Carrier Naic Code
65676
Ins Contract Num
10205901
Ins Prsn Covered End of year Count
136
Ins Policy From Date
2017-07-01
Ins Policy To Date
2018-06-30
Ins Broker Comm Total Amount
$1,527
Ins Broker Fees Total Amount
$394
Alloc Contracts Indiv Indicator
No
Alloc Contracts Group Indicator
No
Alloc Contracts Other Indicator
No
Pens Distr Bnft Terminate Pln Indicator
No
Unalloc Contracts Dep Adm Indicator
No
Unal Contrac Imm Part Guar Indicator
No
Unal Contracts Guar Invest Indicator
No
Unalloc Contracts Other Indicator
No
Wlfr Bnft Health Indicator
No
Wlfr Bnft Dental Indicator
No
Wlfr Bnft Vision Indicator
No
Wlfr Bnft Life Insur Indicator
Yes
Wlfr Bnft Temp Disab Indicator
No
Wlfr Bnft Long Terminate Disab Indicator
No
Wlfr Bnft Unemp Indicator
No
Wlfr Bnft Drug Indicator
No
Wlfr Bnft Stop Loss Indicator
No
Wlfr Bnft Hmo Indicator
No
Wlfr Bnft Ppo Indicator
No
Wlfr Bnft Indemnity Indicator
No
Wlfr Bnft Other Indicator
Yes
Wlfr Type Bnft Oth Text
AD&D
Wlfr Refund Cash Indicator
No
Wlfr Refund Credit Indicator
No
Wlfr Total Charges Paid Amount
$13,966
Ins Fail Provide Info Indicator
No
Row 9
Ins Carrier Name: ANTHEM HEALTH PLANS OF CONNECTICUT, INC.
Form Id
4
Schedule A Plan Year Begin Date
2017-07-01
Schedule A Plan Year End Date
2018-06-30
Schedule A Plan Num
511
Schedule A EIN
06-0646784
Ins Carrier Name
ANTHEM HEALTH PLANS OF CONNECTICUT, INC.
Ins Carrier EIN
06-1475928
Ins Carrier Naic Code
60217
Ins Contract Num
427989
Ins Prsn Covered End of year Count
72
Ins Policy From Date
2017-07-01
Ins Policy To Date
2018-06-30
Ins Broker Comm Total Amount
$3,347
Ins Broker Fees Total Amount
$0
Alloc Contracts Indiv Indicator
No
Alloc Contracts Group Indicator
No
Alloc Contracts Other Indicator
No
Pens Distr Bnft Terminate Pln Indicator
No
Unalloc Contracts Dep Adm Indicator
No
Unal Contrac Imm Part Guar Indicator
No
Unal Contracts Guar Invest Indicator
No
Unalloc Contracts Other Indicator
No
Wlfr Bnft Health Indicator
No
Wlfr Bnft Dental Indicator
Yes
Wlfr Bnft Vision Indicator
No
Wlfr Bnft Life Insur Indicator
No
Wlfr Bnft Temp Disab Indicator
No
Wlfr Bnft Long Terminate Disab Indicator
No
Wlfr Bnft Unemp Indicator
No
Wlfr Bnft Drug Indicator
No
Wlfr Bnft Stop Loss Indicator
No
Wlfr Bnft Hmo Indicator
No
Wlfr Bnft Ppo Indicator
No
Wlfr Bnft Indemnity Indicator
No
Wlfr Bnft Other Indicator
No
Wlfr Refund Cash Indicator
No
Wlfr Refund Credit Indicator
No
Wlfr Total Charges Paid Amount
$66,937
Ins Fail Provide Info Indicator
No

Schedule C

Schedule C Provider

CONNECTICARE

ADMINISTRATOR • EIN 06-1618303

Direct compensation$373,874
Appraisal
Indirect compensationNo
Formula-based compensationNo
Source fields
Row 1
Service code: Appraisal
Service code
Appraisal
CONNECTICARE
Other provider name
CONNECTICARE
Other provider EIN
06-1618303
Relationship to employer or plan
ADMINISTRATOR
Direct compensation
$373,874
Indirect compensation reported
No
Provider Other Elig Indicator Comp Indicator
No
Provider Other Total Indicator Comp Amount
$0
Provider Other Amount Formula Indicator
No

Schedule C Provider

SCHUSTER DRICOLL, LLC

BROKER

Direct compensation$26,125
Indirect compensationNo
Formula-based compensationNo
Source fields
SCHUSTER DRICOLL, LLC
Other provider name
SCHUSTER DRICOLL, LLC
Provider Other US Address1
135 SOUTH ROAD
Provider Other US City
FARMINGTON
Provider Other US State
CT
Provider Other US ZIP
06032
Relationship to employer or plan
BROKER
Direct compensation
$26,125
Indirect compensation reported
No
Provider Other Elig Indicator Comp Indicator
No
Provider Other Total Indicator Comp Amount
$914
Provider Other Amount Formula Indicator
No

Filing received by DOL Jan 31, 2019

Pomfret School Incorporated Welfare Wrap Benefits Plan | Pomfret School Incorporated | Plan 511 | 2017 Form 5500 Filing