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EMPLOYEE BENEFITS MEDICAL & ANCILLARY 401k Plan overview

Plan NameEMPLOYEE BENEFITS MEDICAL & ANCILLARY
Plan identification number 501

EMPLOYEE BENEFITS MEDICAL & ANCILLARY Benefits

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

401k Sponsoring company profile

ESTRELLA MEDIA, INC. has sponsored the creation of one or more 401k plans.

Company Name:ESTRELLA MEDIA, INC.
Employer identification number (EIN):200688078
NAIC Classification:515100

Additional information about ESTRELLA MEDIA, INC.

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2004-03-22
Company Identification Number: 0800319282
Legal Registered Office Address: 1 ESTRELLA WAY

BURBANK
United States of America (USA)
91504

More information about ESTRELLA MEDIA, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFITS MEDICAL & ANCILLARY

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01JACKIE VALDOVINOS2023-12-15
5012021-06-01JACKIE VALDOVINOS2022-11-10
5012020-06-01JACKIE VALDOVINOS2022-02-08
5012020-06-01JACKIE VALDOVINOS2022-02-08
5012019-06-01LAURA MARTINEZ2020-12-16
5012018-06-01LAURA MARTINEZ2019-12-23
5012017-06-01
5012015-06-01ELI KAMIONSKI

Plan Statistics for EMPLOYEE BENEFITS MEDICAL & ANCILLARY

401k plan membership statisitcs for EMPLOYEE BENEFITS MEDICAL & ANCILLARY

Measure Date Value
2022: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2022 401k membership
Total participants, beginning-of-year2022-06-01436
Total number of active participants reported on line 7a of the Form 55002022-06-01405
Number of retired or separated participants receiving benefits2022-06-012
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-01407
Number of employers contributing to the scheme2022-06-010
2021: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2021 401k membership
Total participants, beginning-of-year2021-06-01595
Total number of active participants reported on line 7a of the Form 55002021-06-01476
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01476
Number of employers contributing to the scheme2021-06-010
2020: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2020 401k membership
Total participants, beginning-of-year2020-06-01413
Total number of active participants reported on line 7a of the Form 55002020-06-01344
Number of retired or separated participants receiving benefits2020-06-010
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01344
Number of employers contributing to the scheme2020-06-010
2019: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2019 401k membership
Total participants, beginning-of-year2019-06-01580
Total number of active participants reported on line 7a of the Form 55002019-06-01413
Number of retired or separated participants receiving benefits2019-06-010
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01413
Number of employers contributing to the scheme2019-06-010
2018: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2018 401k membership
Total participants, beginning-of-year2018-06-01532
Total number of active participants reported on line 7a of the Form 55002018-06-01580
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01580
Number of employers contributing to the scheme2018-06-010
2017: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2017 401k membership
Total participants, beginning-of-year2017-06-01540
Total number of active participants reported on line 7a of the Form 55002017-06-01532
Number of retired or separated participants receiving benefits2017-06-010
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01532
Number of employers contributing to the scheme2017-06-010
2015: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2015 401k membership
Total participants, beginning-of-year2015-06-01365
Total number of active participants reported on line 7a of the Form 55002015-06-01358
Number of retired or separated participants receiving benefits2015-06-012
Total of all active and inactive participants2015-06-01360

Form 5500 Responses for EMPLOYEE BENEFITS MEDICAL & ANCILLARY

2022: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – InsuranceYes
2021: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – InsuranceYes
2020: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – InsuranceYes
2019: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – InsuranceYes
2018: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – InsuranceYes
2017: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – InsuranceYes
2015: EMPLOYEE BENEFITS MEDICAL & ANCILLARY 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number302387
Policy instance 6
Insurance contract or identification number302387
Number of Individuals Covered31
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $1,083
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL SERVICES PLAN
Welfare Benefit Premiums Paid to CarrierUSD $5,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $889
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number5944569
Policy instance 5
Insurance contract or identification number5944569
Number of Individuals Covered4
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $115
Total amount of fees paid to insurance companyUSD $14
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number5944569
Policy instance 4
Insurance contract or identification number5944569
Number of Individuals Covered86
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $1,192
Total amount of fees paid to insurance companyUSD $175
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,192
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5944569
Policy instance 3
Insurance contract or identification number5944569
Number of Individuals Covered197
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,626
Total amount of fees paid to insurance companyUSD $384
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,626
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944569
Policy instance 2
Insurance contract or identification number5944569
Number of Individuals Covered542
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $21,412
Total amount of fees paid to insurance companyUSD $3,127
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $215,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,314
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number924188
Policy instance 1
Insurance contract or identification number924188
Number of Individuals Covered454
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $130,578
Total amount of fees paid to insurance companyUSD $12,443
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $2,846,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $130,578
Amount paid for insurance broker fees12443
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number924188
Policy instance 1
Insurance contract or identification number924188
Number of Individuals Covered308
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $146,765
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $2,690,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $146,765
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944569
Policy instance 2
Insurance contract or identification number5944569
Number of Individuals Covered534
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $17,931
Total amount of fees paid to insurance companyUSD $3,245
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $147,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,871
Amount paid for insurance broker fees71
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5944569
Policy instance 3
Insurance contract or identification number5944569
Number of Individuals Covered189
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $2,327
Total amount of fees paid to insurance companyUSD $410
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,327
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number5944569
Policy instance 4
Insurance contract or identification number5944569
Number of Individuals Covered105
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $1,242
Total amount of fees paid to insurance companyUSD $218
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,242
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number5944569
Policy instance 5
Insurance contract or identification number5944569
Number of Individuals Covered9
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $80
Total amount of fees paid to insurance companyUSD $10
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number302387
Policy instance 6
Insurance contract or identification number302387
Number of Individuals Covered29
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $1,017
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL SERVICES PLAN
Welfare Benefit Premiums Paid to CarrierUSD $4,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $754
Amount paid for insurance broker fees0
Insurance broker organization code?4
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number5944569
Policy instance 5
Insurance contract or identification number5944569
Number of Individuals Covered0
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number5944569
Policy instance 4
Insurance contract or identification number5944569
Number of Individuals Covered92
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $1,244
Total amount of fees paid to insurance companyUSD $162
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,244
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION ADDITIONAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5944569
Policy instance 3
Insurance contract or identification number5944569
Number of Individuals Covered184
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,530
Total amount of fees paid to insurance companyUSD $329
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,530
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION ADDITIONAL COMPENSATION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944569
Policy instance 2
Insurance contract or identification number5944569
Number of Individuals Covered435
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $17,421
Total amount of fees paid to insurance companyUSD $2,295
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $186,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,421
Amount paid for insurance broker fees52
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279533
Policy instance 1
Insurance contract or identification number279533
Number of Individuals Covered255
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $143,069
Total amount of fees paid to insurance companyUSD $7,079
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $3,265,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $143,069
Amount paid for insurance broker fees7079
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberD2M71
Policy instance 1
Insurance contract or identification numberD2M71
Number of Individuals Covered67
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $11,660
Total amount of fees paid to insurance companyUSD $282
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $75,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,501
Amount paid for insurance broker fees221
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279533
Policy instance 2
Insurance contract or identification number279533
Number of Individuals Covered467
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $142,996
Total amount of fees paid to insurance companyUSD $8,758
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $3,853,361
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $142,996
Amount paid for insurance broker fees8758
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944569
Policy instance 3
Insurance contract or identification number5944569
Number of Individuals Covered438
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $13,838
Total amount of fees paid to insurance companyUSD $2,258
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $158,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,838
Amount paid for insurance broker fees73
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberNCY70
Policy instance 4
Insurance contract or identification numberNCY70
Number of Individuals Covered6
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $1,628
Total amount of fees paid to insurance companyUSD $133
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $6,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $733
Amount paid for insurance broker fees80
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05944569
Policy instance 5
Insurance contract or identification numberKM05944569
Number of Individuals Covered223
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,195
Total amount of fees paid to insurance companyUSD $350
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,195
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number5944569
Policy instance 6
Insurance contract or identification number5944569
Number of Individuals Covered99
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $957
Total amount of fees paid to insurance companyUSD $152
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $957
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberD2M71
Policy instance 1
Insurance contract or identification numberD2M71
Number of Individuals Covered78
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $15,255
Total amount of fees paid to insurance companyUSD $740
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $107,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,121
Amount paid for insurance broker fees300
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279533
Policy instance 2
Insurance contract or identification number279533
Number of Individuals Covered580
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $144,139
Total amount of fees paid to insurance companyUSD $11,166
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $3,431,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $126,236
Amount paid for insurance broker fees8173
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944569
Policy instance 3
Insurance contract or identification number5944569
Number of Individuals Covered393
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $18,169
Total amount of fees paid to insurance companyUSD $3,448
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $194,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,169
Amount paid for insurance broker fees95
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberNCY70
Policy instance 4
Insurance contract or identification numberNCY70
Number of Individuals Covered7
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,560
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedVOLUNTARY BENEFITS
Welfare Benefit Premiums Paid to CarrierUSD $5,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $536
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05944569
Policy instance 5
Insurance contract or identification numberKM05944569
Number of Individuals Covered220
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $3,617
Total amount of fees paid to insurance companyUSD $670
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,617
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberD2M71
Policy instance 1
Insurance contract or identification numberD2M71
Number of Individuals Covered95
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $20,614
Total amount of fees paid to insurance companyUSD $1,391
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $103,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number279533
Policy instance 2
Insurance contract or identification number279533
Number of Individuals Covered532
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $116,117
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $2,492,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05944569
Policy instance 3
Insurance contract or identification numberKM05944569
Number of Individuals Covered416
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $14,612
Total amount of fees paid to insurance companyUSD $3,622
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $146,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract numberKM05944569
Policy instance 4
Insurance contract or identification numberKM05944569
Number of Individuals Covered237
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,986
Total amount of fees paid to insurance companyUSD $719
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract numberKM05944569
Policy instance 5
Insurance contract or identification numberKM05944569
Number of Individuals Covered85
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $831
Total amount of fees paid to insurance companyUSD $197
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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