FAMILY CARE SPECIALISTS MEDICAL GROUP has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FAMILY CARE SPECIALISTS MEDICAL GROUP
| Measure | Date | Value |
|---|
| 2022: FAMILY CARE SPECIALISTS MEDICAL GROUP 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-05-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 113 |
| Number of retired or separated participants receiving benefits | 2022-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-05-01 | 0 |
| Total of all active and inactive participants | 2022-05-01 | 113 |
| Number of employers contributing to the scheme | 2022-05-01 | 0 |
| 2021: FAMILY CARE SPECIALISTS MEDICAL GROUP 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-05-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 117 |
| Number of retired or separated participants receiving benefits | 2021-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-05-01 | 0 |
| Total of all active and inactive participants | 2021-05-01 | 117 |
| Number of employers contributing to the scheme | 2021-05-01 | 0 |
| 2019: FAMILY CARE SPECIALISTS MEDICAL GROUP 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-05-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 108 |
| Number of retired or separated participants receiving benefits | 2019-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-05-01 | 0 |
| Total of all active and inactive participants | 2019-05-01 | 108 |
| Number of employers contributing to the scheme | 2019-05-01 | 0 |
| 2018: FAMILY CARE SPECIALISTS MEDICAL GROUP 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 108 |
| Number of retired or separated participants receiving benefits | 2018-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 0 |
| Total of all active and inactive participants | 2018-05-01 | 108 |
| Number of employers contributing to the scheme | 2018-05-01 | 0 |
| 2017: FAMILY CARE SPECIALISTS MEDICAL GROUP 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 109 |
| Number of retired or separated participants receiving benefits | 2017-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-05-01 | 0 |
| Total of all active and inactive participants | 2017-05-01 | 109 |
| Number of employers contributing to the scheme | 2017-05-01 | 0 |
| 2016: FAMILY CARE SPECIALISTS MEDICAL GROUP 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 114 |
| Number of retired or separated participants receiving benefits | 2016-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-05-01 | 0 |
| Total of all active and inactive participants | 2016-05-01 | 114 |
| Number of employers contributing to the scheme | 2016-05-01 | 0 |
| 2015: FAMILY CARE SPECIALISTS MEDICAL GROUP 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 114 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 114 |
| Number of employers contributing to the scheme | 2015-05-01 | 0 |
| Total participants, beginning-of-year | 2015-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 112 |
| 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 | 112 |
| Number of employers contributing to the scheme | 2015-01-01 | 0 |
| 2014: FAMILY CARE SPECIALISTS MEDICAL GROUP 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 112 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 112 |
| Number of employers contributing to the scheme | 2014-01-01 | 0 |
| 2013: FAMILY CARE SPECIALISTS MEDICAL GROUP 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 110 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 110 |
| Number of employers contributing to the scheme | 2013-01-01 | 0 |
| 2012: FAMILY CARE SPECIALISTS MEDICAL GROUP 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 118 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 118 |
| Number of employers contributing to the scheme | 2012-01-01 | 0 |
| 2022: FAMILY CARE SPECIALISTS MEDICAL GROUP 2022 form 5500 responses |
|---|
| 2022-05-01 | Type of plan entity | Single employer plan |
| 2022-05-01 | Plan funding arrangement – Insurance | Yes |
| 2022-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: FAMILY CARE SPECIALISTS MEDICAL GROUP 2021 form 5500 responses |
|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: FAMILY CARE SPECIALISTS MEDICAL GROUP 2019 form 5500 responses |
|---|
| 2019-05-01 | Type of plan entity | Single employer plan |
| 2019-05-01 | Plan funding arrangement – Insurance | Yes |
| 2019-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: FAMILY CARE SPECIALISTS MEDICAL GROUP 2018 form 5500 responses |
|---|
| 2018-05-01 | Type of plan entity | Single employer plan |
| 2018-05-01 | Plan funding arrangement – Insurance | Yes |
| 2018-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: FAMILY CARE SPECIALISTS MEDICAL GROUP 2017 form 5500 responses |
|---|
| 2017-05-01 | Type of plan entity | Single employer plan |
| 2017-05-01 | Plan funding arrangement – Insurance | Yes |
| 2017-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: FAMILY CARE SPECIALISTS MEDICAL GROUP 2016 form 5500 responses |
|---|
| 2016-05-01 | Type of plan entity | Single employer plan |
| 2016-05-01 | Plan funding arrangement – Insurance | Yes |
| 2016-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: FAMILY CARE SPECIALISTS MEDICAL GROUP 2015 form 5500 responses |
|---|
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: FAMILY CARE SPECIALISTS MEDICAL GROUP 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: FAMILY CARE SPECIALISTS MEDICAL GROUP 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: FAMILY CARE SPECIALISTS MEDICAL GROUP 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 139374 |
| Policy instance | 3 |
| Insurance contract or identification number | 139374 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $576 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $576 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051737 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $22,374 | | Total amount of fees paid to insurance company | USD $43,785 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $891,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,199 | | Amount paid for insurance broker fees | 43785 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0051737 |
| Policy instance | 1 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $554 | | 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 $4,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $462 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | W0051737 |
| Policy instance | 1 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $454 | | 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 $4,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $454 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051737 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $23,819 | | Total amount of fees paid to insurance company | USD $48,359 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $964,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,522 | | Amount paid for insurance broker fees | 47411 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 139374 |
| Policy instance | 3 |
| Insurance contract or identification number | 139374 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $596 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $596 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051737 |
| Policy instance | 3 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 139374 |
| Policy instance | 2 |
| Insurance contract or identification number | 139374 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $558 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $558 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 139374 |
| Policy instance | 3 |
| Insurance contract or identification number | 139374 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $564 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $564 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051737 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $45,227 | | Total amount of fees paid to insurance company | USD $1,258 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $879,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,227 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $480 | | Total amount of fees paid to insurance company | USD $59 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,795 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $480 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 139374 |
| Policy instance | 3 |
| Insurance contract or identification number | 139374 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $562 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,615 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $562 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0051737 |
| Policy instance | 2 |
| Insurance contract or identification number | W0051737 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $39,091 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $781,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,091 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $497 | | Total amount of fees paid to insurance company | USD $89 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $497 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-04-30 | | Total amount of commissions paid to insurance broker | USD $392 | | Total amount of fees paid to insurance company | USD $71 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $392 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES |
|
| BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $432 | | Total amount of fees paid to insurance company | USD $78 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $432 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT SERVICES |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $92 | | 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 $1,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $92 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $155 | | 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 $5,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $155 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 275838 |
| Policy instance | 1 |
| Insurance contract or identification number | 275838 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $139 | | 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 $3,512 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $139 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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