| Plan Name | BLUE CROSS BLUE SHIELD OF MINNESOTA |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
|
| Company Name: | TRI-COUNTY COMMUNITY ACTION PROGRAM , INC |
| Employer identification number (EIN): | 416050237 |
| NAIC Classification: | 624100 |
| NAIC Description: | Individual and Family Services |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2021-01-01 | TERESA CARTER | 2022-07-24 |
| 2021: BLUE CROSS BLUE SHIELD OF MINNESOTA 2021 form 5500 responses | ||
|---|---|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | First time form 5500 has been submitted | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 ) | |
| Policy contract number | 203194 |
| Policy instance | 1 |