CRIMSON WINE GROUP, LTD has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CRIMSON WINE GROUP HEALTH AND WELFARE PLANS
| Measure | Date | Value |
|---|
| 2022: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 163 |
| 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 | 163 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 151 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 157 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 157 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 157 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 210 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 174 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 174 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-11-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-11-01 | 210 |
| 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 | 3 |
| Total of all active and inactive participants | 2018-11-01 | 213 |
| 2017: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-11-01 | 188 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-11-01 | 208 |
| Number of retired or separated participants receiving benefits | 2017-11-01 | 4 |
| 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 | 212 |
| 2016: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-11-01 | 176 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-11-01 | 185 |
| Number of retired or separated participants receiving benefits | 2016-11-01 | 3 |
| 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 | 188 |
| 2022: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 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 |
| 2021: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2018 form 5500 responses |
|---|
| 2018-11-01 | Type of plan entity | Single employer plan |
| 2018-11-01 | Submission has been amended | No |
| 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) | Yes |
| 2018-11-01 | Plan is a collectively bargained plan | No |
| 2018-11-01 | Plan funding arrangement – Insurance | Yes |
| 2018-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2017 form 5500 responses |
|---|
| 2017-11-01 | Type of plan entity | Single employer plan |
| 2017-11-01 | Submission has been amended | No |
| 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 funding arrangement – General assets of the sponsor | Yes |
| 2017-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CRIMSON WINE GROUP HEALTH AND WELFARE PLANS 2016 form 5500 responses |
|---|
| 2016-11-01 | Type of plan entity | Single employer plan |
| 2016-11-01 | Submission has been amended | No |
| 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 funding arrangement – General assets of the sponsor | Yes |
| 2016-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 919611 |
| Policy instance | 2 |
| Insurance contract or identification number | 919611 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-30 | | Total amount of commissions paid to insurance broker | USD $84,883 | | Total amount of fees paid to insurance company | USD $7,451 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $1,504,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,303 | | Amount paid for insurance broker fees | 7451 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $15,514 | | Total amount of fees paid to insurance company | USD $123 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $554,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,514 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $23,823 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $559,531 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,823 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 2 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,163 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,163 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619865 |
| Policy instance | 3 |
| Insurance contract or identification number | 619865 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,242 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $163,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,242 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 919611 |
| Policy instance | 4 |
| Insurance contract or identification number | 919611 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-30 | | Total amount of commissions paid to insurance broker | USD $54,588 | | Total amount of fees paid to insurance company | USD $7,437 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,029,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,588 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM608442 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM608442 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,131 | | Total amount of fees paid to insurance company | USD $0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $64,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $16,131 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM608442 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM608442 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,540 | | Total amount of fees paid to insurance company | USD $1,586 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $95,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,540 | | Amount paid for insurance broker fees | 1586 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 919611 |
| Policy instance | 4 |
| Insurance contract or identification number | 919611 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-30 | | Total amount of commissions paid to insurance broker | USD $50,868 | | Total amount of fees paid to insurance company | USD $2,451 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $914,323 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,598 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619865 |
| Policy instance | 3 |
| Insurance contract or identification number | 619865 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $15,760 | | Total amount of fees paid to insurance company | USD $1,501 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $158,792 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,665 | | Amount paid for insurance broker fees | 1501 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 2 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,359 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,658 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $874 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $25,157 | | Total amount of fees paid to insurance company | USD $1,131 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $679,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,292 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 1 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $35,351 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $705,473 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,351 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 2 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,164 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,164 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619865 |
| Policy instance | 3 |
| Insurance contract or identification number | 619865 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $18,150 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $182,980 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,150 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619865 |
| Policy instance | 4 |
| Insurance contract or identification number | 619865 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $38,940 | | Total amount of fees paid to insurance company | USD $1,020 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $497,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,940 | | Amount paid for insurance broker fees | 1020 | | Additional information about fees paid to insurance broker | INCENTIVE COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM608442 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM608442 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $13,809 | | Total amount of fees paid to insurance company | USD $1,646 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $92,059 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,809 | | Amount paid for insurance broker fees | 1646 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 619865 |
| Policy instance | 5 |
| Insurance contract or identification number | 619865 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,313 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,313 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM608442 |
| Policy instance | 6 |
| Insurance contract or identification number | SGM608442 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $13,809 | | Total amount of fees paid to insurance company | USD $1,646 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $92,059 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,809 | | Amount paid for insurance broker fees | 1646 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK606184 |
| Policy instance | 1 |
| Insurance contract or identification number | SOK606184 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $751 | | Total amount of fees paid to insurance company | USD $236 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT/EMPLOYEE ASSISTANCE PROGRAM | | 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 $5,004 | | 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: 00000 ) |
| Policy contract number | 30042762 |
| Policy instance | 2 |
| Insurance contract or identification number | 30042762 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $1,181 | | 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 $22,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 0619865 |
| Policy instance | 3 |
| Insurance contract or identification number | 0619865 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $13,486 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $163,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD608975 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD608975 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $3,312 | | Total amount of fees paid to insurance company | USD $1,042 | | 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 | Yes | | 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 $22,077 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD608974 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD608974 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $2,257 | | Total amount of fees paid to insurance company | USD $732 | | 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 | Yes | | 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 $15,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM608442 |
| Policy instance | 6 |
| Insurance contract or identification number | SGM608442 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $1,871 | | Total amount of fees paid to insurance company | USD $1,232 | | 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 | Yes | | 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 $25,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 603743 |
| Policy instance | 7 |
| Insurance contract or identification number | 603743 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $32,302 | | Total amount of fees paid to insurance company | USD $1,084 | | 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 $643,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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