GROW OP FARMS LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-11-01 | 600 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-11-01 | 600 |
| Number of retired or separated participants receiving benefits | 2022-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-11-01 | 0 |
| Total of all active and inactive participants | 2022-11-01 | 600 |
| Number of employers contributing to the scheme | 2022-11-01 | 0 |
| 2021: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-11-01 | 600 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-11-01 | 600 |
| Number of retired or separated participants receiving benefits | 2021-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-11-01 | 0 |
| Total of all active and inactive participants | 2021-11-01 | 600 |
| Number of employers contributing to the scheme | 2021-11-01 | 0 |
| 2020: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-11-01 | 319 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-11-01 | 600 |
| Number of retired or separated participants receiving benefits | 2020-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-11-01 | 0 |
| Total of all active and inactive participants | 2020-11-01 | 600 |
| Number of employers contributing to the scheme | 2020-11-01 | 0 |
| 2019: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-11-01 | 369 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-11-01 | 319 |
| Number of retired or separated participants receiving benefits | 2019-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-11-01 | 0 |
| Total of all active and inactive participants | 2019-11-01 | 319 |
| 2018: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-11-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-11-01 | 279 |
| Number of retired or separated participants receiving benefits | 2018-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-11-01 | 0 |
| Total of all active and inactive participants | 2018-11-01 | 279 |
| 2017: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-11-01 | 181 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-11-01 | 257 |
| Number of retired or separated participants receiving benefits | 2017-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-11-01 | 0 |
| Total of all active and inactive participants | 2017-11-01 | 257 |
| 2016: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-11-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-11-01 | 187 |
| Number of retired or separated participants receiving benefits | 2016-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-11-01 | 0 |
| Total of all active and inactive participants | 2016-11-01 | 187 |
| 2022: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-11-01 | Type of plan entity | Single employer plan |
| 2022-11-01 | Plan funding arrangement – Insurance | Yes |
| 2022-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-11-01 | Type of plan entity | Single employer plan |
| 2021-11-01 | Plan funding arrangement – Insurance | Yes |
| 2021-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-11-01 | Type of plan entity | Single employer plan |
| 2020-11-01 | Plan funding arrangement – Insurance | Yes |
| 2020-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-11-01 | Type of plan entity | Single employer plan |
| 2019-11-01 | Submission has been amended | No |
| 2019-11-01 | This submission is the final filing | No |
| 2019-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-11-01 | Plan is a collectively bargained plan | No |
| 2019-11-01 | Plan funding arrangement – Insurance | Yes |
| 2019-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-11-01 | Type of plan entity | Single employer plan |
| 2018-11-01 | Submission has been amended | Yes |
| 2018-11-01 | This submission is the final filing | No |
| 2018-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-11-01 | Plan is a collectively bargained plan | No |
| 2018-11-01 | Plan funding arrangement – Insurance | Yes |
| 2018-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-11-01 | Type of plan entity | Single employer plan |
| 2017-11-01 | Submission has been amended | Yes |
| 2017-11-01 | This submission is the final filing | No |
| 2017-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-11-01 | Plan is a collectively bargained plan | No |
| 2017-11-01 | Plan funding arrangement – Insurance | Yes |
| 2017-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: GROW OP FARMS LLC EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-11-01 | Type of plan entity | Single employer plan |
| 2016-11-01 | First time form 5500 has been submitted | Yes |
| 2016-11-01 | Submission has been amended | Yes |
| 2016-11-01 | This submission is the final filing | No |
| 2016-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-11-01 | Plan is a collectively bargained plan | No |
| 2016-11-01 | Plan funding arrangement – Insurance | Yes |
| 2016-11-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI961926 |
| Policy instance | 8 |
| Insurance contract or identification number | AI961926 | | Number of Individuals Covered | 600 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $2,578 | | Total amount of fees paid to insurance company | USD $3,077 | | 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 | ACCIDENT,HOSPITAL,CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $30,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 3077 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 4177600 |
| Policy instance | 1 |
| Insurance contract or identification number | 4177600 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $19,328 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $381,824 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,328 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8798900 |
| Policy instance | 2 |
| Insurance contract or identification number | 8798900 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $32,476 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $649,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,476 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA661 |
| Policy instance | 3 |
| Insurance contract or identification number | WA661 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $5,488 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,488 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9795 |
| Policy instance | 4 |
| Insurance contract or identification number | 9795 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $3,905 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,905 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 5 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GRP00006396 |
| Policy instance | 6 |
| Insurance contract or identification number | GRP00006396 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $7,701 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $38,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,701 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15187419 |
| Policy instance | 7 |
| Insurance contract or identification number | 15187419 | | Number of Individuals Covered | 600 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 4177600 |
| Policy instance | 1 |
| Insurance contract or identification number | 4177600 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $15,600 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $348,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,600 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8798900 |
| Policy instance | 2 |
| Insurance contract or identification number | 8798900 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $33,460 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $743,676 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,460 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA661 |
| Policy instance | 3 |
| Insurance contract or identification number | WA661 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $7,398 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $7,398 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 09795 |
| Policy instance | 4 |
| Insurance contract or identification number | 09795 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $1,989 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,989 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 5 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GRP00006396 |
| Policy instance | 6 |
| Insurance contract or identification number | GRP00006396 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $8,632 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $43,158 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,632 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 15187419 |
| Policy instance | 7 |
| Insurance contract or identification number | 15187419 | | Number of Individuals Covered | 600 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI961926 |
| Policy instance | 8 |
| Insurance contract or identification number | AI961926 | | Number of Individuals Covered | 600 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $11,224 | | Total amount of fees paid to insurance company | USD $4,886 | | 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 | ACCIDENT,HOSPITAL,CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $58,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,298 | | Amount paid for insurance broker fees | 2558 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 200268 |
| Policy instance | 6 |
| Insurance contract or identification number | 200268 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $7,987 | | Total amount of fees paid to insurance company | USD $1,073 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,423 | | Amount paid for insurance broker fees | 124 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8798900 |
| Policy instance | 5 |
| Insurance contract or identification number | 8798900 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $43,366 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $848,863 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,366 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 4 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $-2 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-2 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 4177600 |
| Policy instance | 3 |
| Insurance contract or identification number | 4177600 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $16,704 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $308,790 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,704 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA661 |
| Policy instance | 2 |
| Insurance contract or identification number | WA661 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $9,151 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,151 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| INTEGRATED BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | GROWOP |
| Policy instance | 1 |
| Insurance contract or identification number | GROWOP | | Number of Individuals Covered | 600 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $9,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ASURIS NORTHWEST HEALTH (National Association of Insurance Commissioners NAIC id number: 47350 ) |
| Policy contract number | 10019294 |
| Policy instance | 1 |
| Insurance contract or identification number | 10019294 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $88 | | Total amount of fees paid to insurance company | USD $6,260 | | 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 $1,048,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88 | | Amount paid for insurance broker fees | 6260 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5932617 |
| Policy instance | 2 |
| Insurance contract or identification number | 5932617 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $4,725 | | Total amount of fees paid to insurance company | USD $1,146 | | 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 | Yes | | 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 | SUPPLEMENTAL LIFE, SUPPLEMENTAL AD&D | | 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 $21,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,265 | | Amount paid for insurance broker fees | 56 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 3 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $1,186 | | 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 $22,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,186 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0200268 |
| Policy instance | 4 |
| Insurance contract or identification number | 0200268 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $5,073 | | Total amount of fees paid to insurance company | USD $270 | | 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 | ACCIDENT | | 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 $26,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,804 | | Amount paid for insurance broker fees | 56 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA661 |
| Policy instance | 5 |
| Insurance contract or identification number | WA661 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $8,176 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,176 | | Insurance broker organization code? | 3 |
|
| ASURIS NORTHWEST HEALTH (National Association of Insurance Commissioners NAIC id number: 47350 ) |
| Policy contract number | 10019294 |
| Policy instance | 1 |
| Insurance contract or identification number | 10019294 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $61,128 | | 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 $1,145,536 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,128 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5932617 |
| Policy instance | 2 |
| Insurance contract or identification number | 5932617 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $11,991 | | Total amount of fees paid to insurance company | USD $1,024 | | 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 | Yes | | 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 | AD&D, SUPPLEMENTAL LIFE, SUPPLEMENTAL AD&D | | 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 $124,606 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,260 | | Amount paid for insurance broker fees | 25 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 3 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $1,136 | | 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 $21,047 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,136 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0200268 |
| Policy instance | 4 |
| Insurance contract or identification number | 0200268 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $4,176 | | Total amount of fees paid to insurance company | USD $171 | | 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 | ACCIDENT | | 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 $22,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,189 | | Amount paid for insurance broker fees | 25 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA661 |
| Policy instance | 5 |
| Insurance contract or identification number | WA661 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $4,581 | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,581 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0200268 |
| Policy instance | 4 |
| Insurance contract or identification number | 0200268 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $3,309 | | Total amount of fees paid to insurance company | USD $851 | | 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 | ACCIDENT | | 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 $16,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30061499 |
| Policy instance | 3 |
| Insurance contract or identification number | 30061499 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $974 | | 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 $16,279 | | 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 number | 5932617 |
| Policy instance | 2 |
| Insurance contract or identification number | 5932617 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $10,931 | | Total amount of fees paid to insurance company | USD $5,192 | | 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 | Yes | | 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 | AD&D | | 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 $124,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ASURIS NORTHWEST HEALTH (National Association of Insurance Commissioners NAIC id number: 47350 ) |
| Policy contract number | 10019294 |
| Policy instance | 1 |
| Insurance contract or identification number | 10019294 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $38,394 | | Total amount of fees paid to insurance company | USD $3,720 | | 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 $848,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
