PB&J AUTOMOTIVE, INC. DBA TUSTIN MAZDA/TUSTIN HYUNDAI has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN
| 2023: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-06-01 | Type of plan entity | Single employer plan |
| 2023-06-01 | Submission has been amended | No |
| 2023-06-01 | This submission is the final filing | No |
| 2023-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-06-01 | Plan is a collectively bargained plan | No |
| 2023-06-01 | Plan funding arrangement – Insurance | Yes |
| 2023-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-02-01 | Type of plan entity | Single employer plan |
| 2023-02-01 | Submission has been amended | No |
| 2023-02-01 | This submission is the final filing | No |
| 2023-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2023-02-01 | Plan is a collectively bargained plan | No |
| 2023-02-01 | Plan funding arrangement – Insurance | Yes |
| 2023-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | No |
| 2022-02-01 | This submission is the final filing | No |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-02-01 | Plan is a collectively bargained plan | No |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Submission has been amended | No |
| 2021-02-01 | This submission is the final filing | No |
| 2021-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-02-01 | Plan is a collectively bargained plan | No |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | No |
| 2020-02-01 | This submission is the final filing | No |
| 2020-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-02-01 | Plan is a collectively bargained plan | No |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – Insurance | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: PB &J AUTOMOTIVE, INC. DBA TUSTIN MAZDA WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | First time form 5500 has been submitted | Yes |
| 2011-02-01 | Submission has been amended | No |
| 2011-02-01 | This submission is the final filing | No |
| 2011-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-02-01 | Plan is a collectively bargained plan | No |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10440961001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10440961001 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $1,194 | | 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 $11,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 0187788HNO |
| Policy instance | 4 |
| Insurance contract or identification number | 0187788HNO | | Number of Individuals Covered | 148 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $37,815 | | Total amount of fees paid to insurance company | USD $2,500 | | 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 $814,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| Insurance contract or identification number | 00444115 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $26,468 | | Total amount of fees paid to insurance company | USD $8,120 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $157,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| Insurance contract or identification number | 231266 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $37,682 | | 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 $819,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0187788 |
| Policy instance | 5 |
| Insurance contract or identification number | 0187788 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $841 | | Total amount of fees paid to insurance company | USD $2,310 | | 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 $18,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10440961001 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282892 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| Insurance contract or identification number | 00444115 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $26,451 | | Total amount of fees paid to insurance company | USD $7,999 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $156,292 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282892 |
| Policy instance | 4 |
| Insurance contract or identification number | 282892 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $46,929 | | 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 | 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 $793,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 296-069 |
| Policy instance | 1 |
| Insurance contract or identification number | 296-069 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $1,116 | | 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 $11,165 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| Insurance contract or identification number | 231266 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $10,481 | | 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 $237,832 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 296-069 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282892 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 290-069 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282892 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 290-069 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 296-069 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 3 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 296-069 |
| Policy instance | 1 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 227182 |
| Policy instance | 5 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00444115 |
| Policy instance | 4 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1016765 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 296-069 |
| Policy instance | 1 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 227182 |
| Policy instance | 5 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9813312 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1016765 |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | GH683, GH85 |
| Policy instance | 4 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 227182 |
| Policy instance | 5 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | GH683, GH85 |
| Policy instance | 4 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1016765 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 2 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9813312 |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 2 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 8 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 231266 |
| Policy instance | 3 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1016765 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | GH683, GH85 |
| Policy instance | 5 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 6 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 7 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9813312 |
| Policy instance | 1 |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1016765 |
| Policy instance | 8 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | GH683, ZP598 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US434990 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 806199 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 5 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 6 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AIX5 |
| Policy instance | 7 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9813312 |
| Policy instance | 1 |
