401k Plan data: EVIDENT CHANGE HEALTH AND WELFARE PLAN plan

EVIDENT CHANGE HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	EVIDENT CHANGE HEALTH AND WELFARE PLAN
Plan identification number	501

EVIDENT CHANGE HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

EVIDENT CHANGE has sponsored the creation of one or more 401k plans.

Company Name: EVIDENT CHANGE

Employer identification number (EIN): 131624111

NAIC Classification: 541700

Additional information about EVIDENT CHANGE

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1921-12-14

Company Identification Number: 17529

Legal Registered Office Address: ONE COMMERCE PLAZA - 99 WASHINGTON AVE.
SUITE 805-A
ALBANY
United States of America (USA)
122102822

More information about EVIDENT CHANGE

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EVIDENT CHANGE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 MINDY ROWLAND 2023-04-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	MINDY ROWLAND	2023-04-27

Plan Statistics for EVIDENT CHANGE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for EVIDENT CHANGE HEALTH AND WELFARE PLAN

Measure Date Value
2022: EVIDENT CHANGE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 111
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 111
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: EVIDENT CHANGE HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	111
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	111
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for EVIDENT CHANGE HEALTH AND WELFARE PLAN

2022: EVIDENT CHANGE HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )

Policy contract number

L04645

Policy instance

Insurance contract or identification number	L04645
Number of Individuals Covered	148
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $50,851
Total amount of fees paid to insurance company	USD $1,800
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,104,768
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,851
Amount paid for insurance broker fees	1800
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

604571

Policy instance

Insurance contract or identification number	604571
Number of Individuals Covered	12
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,440
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,440
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1070367

Policy instance

Insurance contract or identification number	1070367
Number of Individuals Covered	195
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,601
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $146,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,601
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

CM10001260

Policy instance

Insurance contract or identification number	CM10001260
Number of Individuals Covered	36
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,527
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,527
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	EVIDENT CHANGE
Employer identification number (EIN):	131624111
NAIC Classification:	541700

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1921-12-14
Company Identification Number:	17529
Legal Registered Office Address:	ONE COMMERCE PLAZA - 99 WASHINGTON AVE. SUITE 805-A ALBANY United States of America (USA) 122102822