401k Plan data: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA plan

MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 401k Plan overview

Plan Name	MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA
Plan identification number	501

MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

RESA POWER, LLC has sponsored the creation of one or more 401k plans.

Company Name: RESA POWER, LLC

Employer identification number (EIN): 452810331

NAIC Classification: 423600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01
501 2016-01-01
501 2015-01-01 RAUL TEJADA
501 2014-05-01 CAROLYN MCCORMICK
501 2013-05-01 CAROLYN MCCORMICK
501 2012-05-01 CAROLYN MCCORMICK

Plan Statistics for MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA

401k plan membership statisitcs for MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA

Measure Date Value
2017: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2017 401k membership
Total participants, beginning-of-year 2017-01-01 204
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
2016: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2016 401k membership
Total participants, beginning-of-year 2016-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 154
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 154
2015: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2015 401k membership
Total participants, beginning-of-year 2015-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 130
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 130
2014: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2014 401k membership
Total participants, beginning-of-year 2014-05-01 113
Total number of active participants reported on line 7a of the Form 5500 2014-05-01 119
Number of retired or separated participants receiving benefits 2014-05-01 0
Number of other retired or separated participants entitled to future benefits 2014-05-01 0
Total of all active and inactive participants 2014-05-01 119
2013: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2013 401k membership
Total participants, beginning-of-year 2013-05-01 90
Total number of active participants reported on line 7a of the Form 5500 2013-05-01 113
Number of retired or separated participants receiving benefits 2013-05-01 0
Number of other retired or separated participants entitled to future benefits 2013-05-01 0
Total of all active and inactive participants 2013-05-01 113
2012: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2012 401k membership
Total participants, beginning-of-year 2012-05-01 125
Total number of active participants reported on line 7a of the Form 5500 2012-05-01 90
Number of retired or separated participants receiving benefits 2012-05-01 0
Number of other retired or separated participants entitled to future benefits 2012-05-01 0
Total of all active and inactive participants 2012-05-01 90

Measure	Date	Value
2017: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2017 401k membership
Total participants, beginning-of-year	2017-01-01	204
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
2016: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2016 401k membership
Total participants, beginning-of-year	2016-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	154
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	154
2015: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2015 401k membership
Total participants, beginning-of-year	2015-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	130
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	130
2014: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2014 401k membership
Total participants, beginning-of-year	2014-05-01	113
Total number of active participants reported on line 7a of the Form 5500	2014-05-01	119
Number of retired or separated participants receiving benefits	2014-05-01	0
Number of other retired or separated participants entitled to future benefits	2014-05-01	0
Total of all active and inactive participants	2014-05-01	119
2013: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2013 401k membership
Total participants, beginning-of-year	2013-05-01	90
Total number of active participants reported on line 7a of the Form 5500	2013-05-01	113
Number of retired or separated participants receiving benefits	2013-05-01	0
Number of other retired or separated participants entitled to future benefits	2013-05-01	0
Total of all active and inactive participants	2013-05-01	113
2012: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2012 401k membership
Total participants, beginning-of-year	2012-05-01	125
Total number of active participants reported on line 7a of the Form 5500	2012-05-01	90
Number of retired or separated participants receiving benefits	2012-05-01	0
Number of other retired or separated participants entitled to future benefits	2012-05-01	0
Total of all active and inactive participants	2012-05-01	90

Form 5500 Responses for MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA

2017: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	This submission is the final filing	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2014 form 5500 responses
2014-05-01	Type of plan entity	Single employer plan
2014-05-01	Submission has been amended	No
2014-05-01	This submission is the final filing	No
2014-05-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-05-01	Plan is a collectively bargained plan	No
2014-05-01	Plan funding arrangement – Insurance	Yes
2014-05-01	Plan benefit arrangement – Insurance	Yes
2013: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2013 form 5500 responses
2013-05-01	Type of plan entity	Single employer plan
2013-05-01	Submission has been amended	No
2013-05-01	This submission is the final filing	No
2013-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-05-01	Plan is a collectively bargained plan	No
2013-05-01	Plan funding arrangement – Insurance	Yes
2013-05-01	Plan benefit arrangement – Insurance	Yes
2012: MEDICAL BLUE CROSS BLUE SHIELD OF CALIFORNIA 2012 form 5500 responses
2012-05-01	Type of plan entity	Single employer plan
2012-05-01	First time form 5500 has been submitted	Yes
2012-05-01	Submission has been amended	No
2012-05-01	This submission is the final filing	No
2012-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-05-01	Plan is a collectively bargained plan	No
2012-05-01	Plan funding arrangement – Insurance	Yes
2012-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

906625

Policy instance

Insurance contract or identification number	906625
Number of Individuals Covered	513
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $124,026
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,349,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,532
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BROWN AND BROWN OF FLORIDA, INC.

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0002649

Policy instance

Insurance contract or identification number	W0002649
Number of Individuals Covered	343
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $86,741
Total amount of fees paid to insurance company	USD $64
Are there contracts with allocated funds for individual policies?	No
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 $1,734,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $86,741
Amount paid for insurance broker fees	64
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	NEOVIA INTEGRATED INSURANCE SVCS.

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0002649

Policy instance

Insurance contract or identification number	W0002649
Number of Individuals Covered	283
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $59,573
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,191,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $59,573
Insurance broker organization code?	3
Insurance broker name	NEOVIA INTEGRATED INSURANCE SVCS.

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

932292/W0002649

Policy instance

Insurance contract or identification number	932292/W0002649
Number of Individuals Covered	258
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $51,779
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,035,572
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,779
Insurance broker organization code?	3
Insurance broker name	NEOVIA INTEGRATED INSURANCE SVCS.

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

932292

Policy instance

Insurance contract or identification number	932292
Number of Individuals Covered	207
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $44,006
Total amount of fees paid to insurance company	USD $14,537
Are there contracts with allocated funds for individual policies?	No
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 $879,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,342
Amount paid for insurance broker fees	14537
Additional information about fees paid to insurance broker	GENERAL AGENT SERVICES
Insurance broker organization code?	3
Insurance broker name	INTEGRATED INSURANCE SERVICES

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Company Name:	RESA POWER, LLC
Employer identification number (EIN):	452810331
NAIC Classification:	423600