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PACIFIC HEALTH TRUST 401k Plan overview

Plan NamePACIFIC HEALTH TRUST
Plan identification number 501

PACIFIC HEALTH TRUST Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision

401k Sponsoring company profile

TRUSTEE - PACIFIC HEALTH TRUST has sponsored the creation of one or more 401k plans.

Company Name:TRUSTEE - PACIFIC HEALTH TRUST
Employer identification number (EIN):206201813
NAIC Classification:525100
NAIC Description: Insurance and Employee Benefit Funds

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACIFIC HEALTH TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012014-06-01WYNONA BUCK
5012013-06-01WYNONA OWENS
5012012-06-01WYNONA OWENS
5012011-06-01MICHELE DIMMETT
5012010-06-01MICHELE DIMMETT
5012009-06-01 MICHELE DIMMETT2011-02-25
5012009-06-01MICHELE DIMMETT

Plan Statistics for PACIFIC HEALTH TRUST

401k plan membership statisitcs for PACIFIC HEALTH TRUST

Measure Date Value
2014: PACIFIC HEALTH TRUST 2014 401k membership
Total participants, beginning-of-year2014-06-01843
Total number of active participants reported on line 7a of the Form 55002014-06-010
Number of retired or separated participants receiving benefits2014-06-010
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-010
2013: PACIFIC HEALTH TRUST 2013 401k membership
Total participants, beginning-of-year2013-06-01892
Total number of active participants reported on line 7a of the Form 55002013-06-01836
Number of retired or separated participants receiving benefits2013-06-017
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01843
2012: PACIFIC HEALTH TRUST 2012 401k membership
Total participants, beginning-of-year2012-06-01806
Total number of active participants reported on line 7a of the Form 55002012-06-01885
Number of retired or separated participants receiving benefits2012-06-017
Number of other retired or separated participants entitled to future benefits2012-06-010
Total of all active and inactive participants2012-06-01892
2011: PACIFIC HEALTH TRUST 2011 401k membership
Total participants, beginning-of-year2011-06-01245
Total number of active participants reported on line 7a of the Form 55002011-06-01804
Number of retired or separated participants receiving benefits2011-06-012
Total of all active and inactive participants2011-06-01806
Total participants2011-06-01806
2010: PACIFIC HEALTH TRUST 2010 401k membership
Total participants, beginning-of-year2010-06-01354
Total number of active participants reported on line 7a of the Form 55002010-06-01245
Number of retired or separated participants receiving benefits2010-06-010
Number of other retired or separated participants entitled to future benefits2010-06-010
Total of all active and inactive participants2010-06-01245
Total participants2010-06-01245
2009: PACIFIC HEALTH TRUST 2009 401k membership
Total participants, beginning-of-year2009-06-01410
Total number of active participants reported on line 7a of the Form 55002009-06-01354
Number of retired or separated participants receiving benefits2009-06-010
Number of other retired or separated participants entitled to future benefits2009-06-010
Total of all active and inactive participants2009-06-01354

Financial Data on PACIFIC HEALTH TRUST

Measure Date Value
2015 : PACIFIC HEALTH TRUST 2015 401k financial data
Total unrealized appreciation/depreciation of assets2015-05-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-05-31$81,459
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-05-31$20,499
Total income from all sources (including contributions)2015-05-31$2,338,179
Total loss/gain on sale of assets2015-05-31$0
Total of all expenses incurred2015-05-31$2,411,813
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2015-05-31$2,185,476
Total contributions o plan (from employers,participants, others, non cash contrinutions)2015-05-31$2,338,179
Value of total assets at end of year2015-05-31$81,459
Value of total assets at beginning of year2015-05-31$94,133
Total of administrative expenses incurred including professional, contract, advisory and management fees2015-05-31$226,337
Total interest from all sources2015-05-31$0
Total dividends received (eg from common stock, registered investment company shares)2015-05-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-05-31No
Administrative expenses professional fees incurred2015-05-31$154,053
Was this plan covered by a fidelity bond2015-05-31Yes
Value of fidelity bond cover2015-05-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2015-05-31No
Contributions received from participants2015-05-31$17,091
Value of other receiveables (less allowance for doubtful accounts) at end of year2015-05-31$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2015-05-31$5,614
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2015-05-31$61,507
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2015-05-31$20,499
Administrative expenses (other) incurred2015-05-31$22,001
Total non interest bearing cash at end of year2015-05-31$79,981
Total non interest bearing cash at beginning of year2015-05-31$88,519
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-05-31No
Value of net income/loss2015-05-31$-73,634
Value of net assets at end of year (total assets less liabilities)2015-05-31$0
Value of net assets at beginning of year (total assets less liabilities)2015-05-31$73,634
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-05-31No
Were any leases to which the plan was party in default or uncollectible2015-05-31No
Investment advisory and management fees2015-05-31$0
Expenses. Payments to insurance carriers foe the provision of benefits2015-05-31$2,185,476
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-05-31No
Was there a failure to transmit to the plan any participant contributions2015-05-31No
Has the plan failed to provide any benefit when due under the plan2015-05-31No
Contributions received in cash from employer2015-05-31$2,321,088
Employer contributions (assets) at end of year2015-05-31$1,478
Employer contributions (assets) at beginning of year2015-05-31$0
Contract administrator fees2015-05-31$50,283
Liabilities. Value of benefit claims payable at end of year2015-05-31$19,952
Liabilities. Value of benefit claims payable at beginning of year2015-05-31$0
Did the plan have assets held for investment2015-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2015-05-31No
Opinion of an independent qualified public accountant for this plan2015-05-31Unqualified
Accountancy firm name2015-05-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2015-05-31410746749
2014 : PACIFIC HEALTH TRUST 2014 401k financial data
Total unrealized appreciation/depreciation of assets2014-05-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-05-31$20,499
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2014-05-31$10,015
Total income from all sources (including contributions)2014-05-31$6,027,320
Total loss/gain on sale of assets2014-05-31$0
Total of all expenses incurred2014-05-31$6,030,248
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2014-05-31$5,521,549
Total contributions o plan (from employers,participants, others, non cash contrinutions)2014-05-31$6,027,320
Value of total assets at end of year2014-05-31$94,133
Value of total assets at beginning of year2014-05-31$86,577
Total of administrative expenses incurred including professional, contract, advisory and management fees2014-05-31$508,699
Total interest from all sources2014-05-31$0
Total dividends received (eg from common stock, registered investment company shares)2014-05-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-05-31No
Administrative expenses professional fees incurred2014-05-31$432,237
Was this plan covered by a fidelity bond2014-05-31Yes
Value of fidelity bond cover2014-05-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2014-05-31No
Contributions received from participants2014-05-31$28,765
Value of other receiveables (less allowance for doubtful accounts) at end of year2014-05-31$5,614
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2014-05-31$2,734
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2014-05-31$20,499
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2014-05-31$1,235
Administrative expenses (other) incurred2014-05-31$4,333
Total non interest bearing cash at end of year2014-05-31$88,519
Total non interest bearing cash at beginning of year2014-05-31$78,556
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-05-31No
Value of net income/loss2014-05-31$-2,928
Value of net assets at end of year (total assets less liabilities)2014-05-31$73,634
Value of net assets at beginning of year (total assets less liabilities)2014-05-31$76,562
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-05-31No
Were any leases to which the plan was party in default or uncollectible2014-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2014-05-31$5,521,549
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-05-31No
Was there a failure to transmit to the plan any participant contributions2014-05-31No
Has the plan failed to provide any benefit when due under the plan2014-05-31No
Contributions received in cash from employer2014-05-31$5,998,555
Employer contributions (assets) at end of year2014-05-31$0
Employer contributions (assets) at beginning of year2014-05-31$5,287
Contract administrator fees2014-05-31$72,129
Liabilities. Value of benefit claims payable at end of year2014-05-31$0
Liabilities. Value of benefit claims payable at beginning of year2014-05-31$8,780
Did the plan have assets held for investment2014-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2014-05-31No
Opinion of an independent qualified public accountant for this plan2014-05-31Unqualified
Accountancy firm name2014-05-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2014-05-31410746749
2013 : PACIFIC HEALTH TRUST 2013 401k financial data
Total unrealized appreciation/depreciation of assets2013-05-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-05-31$10,015
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2013-05-31$13,789
Total income from all sources (including contributions)2013-05-31$6,032,319
Total loss/gain on sale of assets2013-05-31$0
Total of all expenses incurred2013-05-31$5,992,738
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2013-05-31$5,504,874
Total contributions o plan (from employers,participants, others, non cash contrinutions)2013-05-31$6,032,319
Value of total assets at end of year2013-05-31$86,577
Value of total assets at beginning of year2013-05-31$50,770
Total of administrative expenses incurred including professional, contract, advisory and management fees2013-05-31$487,864
Total interest from all sources2013-05-31$0
Total dividends received (eg from common stock, registered investment company shares)2013-05-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-05-31No
Administrative expenses professional fees incurred2013-05-31$411,625
Was this plan covered by a fidelity bond2013-05-31Yes
Value of fidelity bond cover2013-05-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2013-05-31No
Contributions received from participants2013-05-31$19,854
Value of other receiveables (less allowance for doubtful accounts) at end of year2013-05-31$2,734
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2013-05-31$7,690
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2013-05-31$1,235
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2013-05-31$3,217
Administrative expenses (other) incurred2013-05-31$4,422
Total non interest bearing cash at end of year2013-05-31$78,556
Total non interest bearing cash at beginning of year2013-05-31$37,554
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-05-31No
Value of net income/loss2013-05-31$39,581
Value of net assets at end of year (total assets less liabilities)2013-05-31$76,562
Value of net assets at beginning of year (total assets less liabilities)2013-05-31$36,981
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2013-05-31No
Were any leases to which the plan was party in default or uncollectible2013-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2013-05-31$5,504,874
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-05-31No
Was there a failure to transmit to the plan any participant contributions2013-05-31No
Has the plan failed to provide any benefit when due under the plan2013-05-31No
Contributions received in cash from employer2013-05-31$6,012,465
Employer contributions (assets) at end of year2013-05-31$5,287
Employer contributions (assets) at beginning of year2013-05-31$5,526
Contract administrator fees2013-05-31$71,817
Liabilities. Value of benefit claims payable at end of year2013-05-31$8,780
Liabilities. Value of benefit claims payable at beginning of year2013-05-31$10,572
Did the plan have assets held for investment2013-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2013-05-31No
Opinion of an independent qualified public accountant for this plan2013-05-31Unqualified
Accountancy firm name2013-05-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2013-05-31410746749
2012 : PACIFIC HEALTH TRUST 2012 401k financial data
Total unrealized appreciation/depreciation of assets2012-05-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-05-31$13,789
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2012-05-31$21,562
Total income from all sources (including contributions)2012-05-31$3,266,530
Total loss/gain on sale of assets2012-05-31$0
Total of all expenses incurred2012-05-31$3,257,014
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2012-05-31$2,984,138
Total contributions o plan (from employers,participants, others, non cash contrinutions)2012-05-31$3,266,530
Value of total assets at end of year2012-05-31$50,770
Value of total assets at beginning of year2012-05-31$49,027
Total of administrative expenses incurred including professional, contract, advisory and management fees2012-05-31$272,876
Total interest from all sources2012-05-31$0
Total dividends received (eg from common stock, registered investment company shares)2012-05-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-05-31No
Administrative expenses professional fees incurred2012-05-31$225,957
Was this plan covered by a fidelity bond2012-05-31Yes
Value of fidelity bond cover2012-05-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2012-05-31No
Contributions received from participants2012-05-31$10,258
Value of other receiveables (less allowance for doubtful accounts) at end of year2012-05-31$7,690
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2012-05-31$14,874
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2012-05-31$3,217
Administrative expenses (other) incurred2012-05-31$7,408
Liabilities. Value of operating payables at beginning of year2012-05-31$12,166
Total non interest bearing cash at end of year2012-05-31$37,554
Total non interest bearing cash at beginning of year2012-05-31$34,153
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-05-31No
Value of net income/loss2012-05-31$9,516
Value of net assets at end of year (total assets less liabilities)2012-05-31$36,981
Value of net assets at beginning of year (total assets less liabilities)2012-05-31$27,465
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2012-05-31No
Were any leases to which the plan was party in default or uncollectible2012-05-31No
Expenses. Payments to insurance carriers foe the provision of benefits2012-05-31$2,984,138
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-05-31No
Was there a failure to transmit to the plan any participant contributions2012-05-31No
Has the plan failed to provide any benefit when due under the plan2012-05-31No
Contributions received in cash from employer2012-05-31$3,256,272
Employer contributions (assets) at end of year2012-05-31$5,526
Contract administrator fees2012-05-31$39,511
Liabilities. Value of benefit claims payable at end of year2012-05-31$10,572
Liabilities. Value of benefit claims payable at beginning of year2012-05-31$9,396
Did the plan have assets held for investment2012-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2012-05-31No
Opinion of an independent qualified public accountant for this plan2012-05-31Unqualified
Accountancy firm name2012-05-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2012-05-31410746749
2011 : PACIFIC HEALTH TRUST 2011 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2011-05-31$21,562
Total income from all sources (including contributions)2011-05-31$2,273,761
Total of all expenses incurred2011-05-31$2,279,684
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2011-05-31$2,082,345
Total contributions o plan (from employers,participants, others, non cash contrinutions)2011-05-31$2,273,761
Value of total assets at end of year2011-05-31$49,027
Value of total assets at beginning of year2011-05-31$33,388
Total of administrative expenses incurred including professional, contract, advisory and management fees2011-05-31$197,339
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2011-05-31No
Administrative expenses professional fees incurred2011-05-31$127,643
Was this plan covered by a fidelity bond2011-05-31Yes
Value of fidelity bond cover2011-05-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2011-05-31No
Contributions received from participants2011-05-31$16,447
Value of other receiveables (less allowance for doubtful accounts) at end of year2011-05-31$14,874
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2011-05-31$1,843
Administrative expenses (other) incurred2011-05-31$2,604
Liabilities. Value of operating payables at end of year2011-05-31$18,139
Total non interest bearing cash at end of year2011-05-31$34,153
Total non interest bearing cash at beginning of year2011-05-31$31,545
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2011-05-31No
Value of net income/loss2011-05-31$-5,923
Value of net assets at end of year (total assets less liabilities)2011-05-31$27,465
Value of net assets at beginning of year (total assets less liabilities)2011-05-31$33,388
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2011-05-31No
Were any loans by the plan or fixed income obligations due to the plan in default2011-05-31No
Were any leases to which the plan was party in default or uncollectible2011-05-31No
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2011-05-31$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2011-05-31$0
Expenses. Payments to insurance carriers foe the provision of benefits2011-05-31$2,082,345
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2011-05-31No
Was there a failure to transmit to the plan any participant contributions2011-05-31No
Has the plan failed to provide any benefit when due under the plan2011-05-31No
Contributions received in cash from employer2011-05-31$2,257,314
Contract administrator fees2011-05-31$67,092
Liabilities. Value of benefit claims payable at end of year2011-05-31$3,423
Did the plan have assets held for investment2011-05-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2011-05-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2011-05-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2011-05-31No
Opinion of an independent qualified public accountant for this plan2011-05-31Unqualified
Accountancy firm name2011-05-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2011-05-31410746749

Form 5500 Responses for PACIFIC HEALTH TRUST

2014: PACIFIC HEALTH TRUST 2014 form 5500 responses
2014-06-01Type of plan entityMulitple employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – TrustYes
2014-06-01Plan benefit arrangement – InsuranceYes
2013: PACIFIC HEALTH TRUST 2013 form 5500 responses
2013-06-01Type of plan entityMulitple employer plan
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – TrustYes
2013-06-01Plan benefit arrangement – InsuranceYes
2012: PACIFIC HEALTH TRUST 2012 form 5500 responses
2012-06-01Type of plan entityMulitple employer plan
2012-06-01Submission has been amendedNo
2012-06-01This submission is the final filingNo
2012-06-01This return/report is a short plan year return/report (less than 12 months)No
2012-06-01Plan is a collectively bargained planNo
2012-06-01Plan funding arrangement – TrustYes
2012-06-01Plan benefit arrangement – InsuranceYes
2011: PACIFIC HEALTH TRUST 2011 form 5500 responses
2011-06-01Type of plan entityMulitple employer plan
2011-06-01Submission has been amendedNo
2011-06-01This submission is the final filingNo
2011-06-01This return/report is a short plan year return/report (less than 12 months)No
2011-06-01Plan is a collectively bargained planNo
2011-06-01Plan funding arrangement – TrustYes
2011-06-01Plan benefit arrangement – InsuranceYes
2010: PACIFIC HEALTH TRUST 2010 form 5500 responses
2010-06-01Type of plan entityMulitple employer plan
2010-06-01Submission has been amendedYes
2010-06-01This submission is the final filingNo
2010-06-01This return/report is a short plan year return/report (less than 12 months)No
2010-06-01Plan is a collectively bargained planNo
2010-06-01Plan funding arrangement – TrustYes
2010-06-01Plan benefit arrangement – InsuranceYes
2009: PACIFIC HEALTH TRUST 2009 form 5500 responses
2009-06-01Type of plan entityMulitple employer plan
2009-06-01Submission has been amendedNo
2009-06-01This submission is the final filingNo
2009-06-01This return/report is a short plan year return/report (less than 12 months)No
2009-06-01Plan is a collectively bargained planNo
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number30677
Policy instance 2
Insurance contract or identification number30677
Number of Individuals Covered605
Insurance policy start date2014-08-01
Insurance policy end date2015-05-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )
Policy contract number120-121-122-123
Policy instance 1
Insurance contract or identification number120-121-122-123
Number of Individuals Covered51
Insurance policy start date2014-08-01
Insurance policy end date2015-04-30
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPHTW
Policy instance 3
Insurance contract or identification numberPHTW
Number of Individuals Covered0
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Insurance broker nameWILLIS OF OREGON
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number30677
Policy instance 4
Insurance contract or identification number30677
Number of Individuals Covered605
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $42,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )
Policy contract number120-121-122-123
Policy instance 5
Insurance contract or identification number120-121-122-123
Number of Individuals Covered198
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract numberWA-101733
Policy instance 6
Insurance contract or identification numberWA-101733
Number of Individuals Covered0
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPHTW
Policy instance 1
Insurance contract or identification numberPHTW
Number of Individuals Covered920
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,366
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,370,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3366
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameWILLIS OF OREGON INC
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract numberWA-101733
Policy instance 2
Insurance contract or identification numberWA-101733
Number of Individuals Covered847
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $23,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )
Policy contract number120-121-122-123
Policy instance 3
Insurance contract or identification number120-121-122-123
Number of Individuals Covered195
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number30677
Policy instance 4
Insurance contract or identification number30677
Number of Individuals Covered611
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $41,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPHTW
Policy instance 1
Insurance contract or identification numberPHTW
Number of Individuals Covered909
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,876
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,278,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1876
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameWILLIS OF OREGON INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12169901-0008
Policy instance 6
Insurance contract or identification number12169901-0008
Number of Individuals Covered286
Insurance policy start date2012-06-01
Insurance policy end date2013-05-13
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )
Policy contract number120-121-122-123
Policy instance 4
Insurance contract or identification number120-121-122-123
Number of Individuals Covered191
Insurance policy start date2012-08-01
Insurance policy end date2013-05-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number30677
Policy instance 5
Insurance contract or identification number30677
Number of Individuals Covered627
Insurance policy start date2012-08-01
Insurance policy end date2013-05-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $33,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract numberWA-101733
Policy instance 3
Insurance contract or identification numberWA-101733
Number of Individuals Covered752
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $22,581
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 numberG 00-435492
Policy instance 2
Insurance contract or identification numberG 00-435492
Number of Individuals Covered0
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $435
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees435
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameWILLIS OF OREGON INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract numberG 00-435492
Policy instance 3
Insurance contract or identification numberG 00-435492
Number of Individuals Covered166
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $63,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract numberPHTW
Policy instance 2
Insurance contract or identification numberPHTW
Number of Individuals Covered804
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,960,023
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: 39616 )
Policy contract number12169901
Policy instance 1
Insurance contract or identification number12169901
Number of Individuals Covered282
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract numberWA-101733
Policy instance 4
Insurance contract or identification numberWA-101733
Number of Individuals Covered699
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $12,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 )
Policy contract numberWA-101733
Policy instance 3
Insurance contract or identification numberWA-101733
Number of Individuals Covered181
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $6,726
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: 39616 )
Policy contract number12169901
Policy instance 1
Insurance contract or identification number12169901
Number of Individuals Covered61
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $7,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberPHTW
Policy instance 2
Insurance contract or identification numberPHTW
Number of Individuals Covered250
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,236,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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