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POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 401k Plan overview

Plan NamePOMONA COMMUNITY HEALTH CENTER 403(B) PLAN
Plan identification number 001

POMONA COMMUNITY HEALTH CENTER 403(B) PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 403(b)(7) accounts - See Limited Pension Plan Reporting instructions for Code section 403(b)(7) custodial accounts for regulated investment company stock for certain exempt organizations.
  • Participant-directed brokerage accounts provided as an investment option under the plan.
  • Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

POMONA COMMUNITY HEALTH CENTER has sponsored the creation of one or more 401k plans.

Company Name:POMONA COMMUNITY HEALTH CENTER
Employer identification number (EIN):223914738
NAIC Classification:621498
NAIC Description:All Other Outpatient Care Centers

Additional information about POMONA COMMUNITY HEALTH CENTER

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: C2767399

More information about POMONA COMMUNITY HEALTH CENTER

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POMONA COMMUNITY HEALTH CENTER 403(B) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0012022-01-01
0012021-01-01
0012020-01-01
0012020-01-01
0012020-01-01
0012019-01-01
0012019-01-01
0012018-01-01ELLEN SILVER2019-08-21
0012017-01-01AGUILERA, ALFONSO2018-08-02
0012016-01-01ELLEN R, SILVER2017-05-18 ELLEN R. SILVER2017-05-18
0012015-01-01ELLEN SILVER2016-04-28 ELLEN SILVER2016-04-28

Plan Statistics for POMONA COMMUNITY HEALTH CENTER 403(B) PLAN

401k plan membership statisitcs for POMONA COMMUNITY HEALTH CENTER 403(B) PLAN

Measure Date Value
2022: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01208
Total number of active participants reported on line 7a of the Form 55002022-01-01130
Number of retired or separated participants receiving benefits2022-01-018
Number of other retired or separated participants entitled to future benefits2022-01-0196
Total of all active and inactive participants2022-01-01234
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2022-01-010
Total participants2022-01-01234
Number of participants with account balances2022-01-01190
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2022-01-010
2021: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01200
Total number of active participants reported on line 7a of the Form 55002021-01-01120
Number of retired or separated participants receiving benefits2021-01-016
Number of other retired or separated participants entitled to future benefits2021-01-0182
Total of all active and inactive participants2021-01-01208
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2021-01-010
Total participants2021-01-01208
Number of participants with account balances2021-01-01180
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2021-01-010
2020: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01173
Total number of active participants reported on line 7a of the Form 55002020-01-01139
Number of retired or separated participants receiving benefits2020-01-015
Number of other retired or separated participants entitled to future benefits2020-01-0156
Total of all active and inactive participants2020-01-01200
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2020-01-010
Total participants2020-01-01200
Number of participants with account balances2020-01-01158
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2020-01-010
2019: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01142
Total number of active participants reported on line 7a of the Form 55002019-01-01123
Number of retired or separated participants receiving benefits2019-01-013
Number of other retired or separated participants entitled to future benefits2019-01-0146
Total of all active and inactive participants2019-01-01172
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2019-01-010
Total participants2019-01-01172
Number of participants with account balances2019-01-01142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2019-01-010

Financial Data on POMONA COMMUNITY HEALTH CENTER 403(B) PLAN

Measure Date Value
2022 : POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets2022-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$0
Total income from all sources (including contributions)2022-12-31$-11,095
Total loss/gain on sale of assets2022-12-31$0
Total of all expenses incurred2022-12-31$109,186
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$107,084
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$509,484
Value of total assets at end of year2022-12-31$2,689,465
Value of total assets at beginning of year2022-12-31$2,809,746
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$2,102
Total interest from all sources2022-12-31$3,039
Total dividends received (eg from common stock, registered investment company shares)2022-12-31$66,029
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Total dividends received from registered investment company shares (eg mutual funds)2022-12-31$66,029
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$300,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$380,147
Participant contributions at end of year2022-12-31$62,282
Participant contributions at beginning of year2022-12-31$35,516
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$-120,281
Value of net assets at end of year (total assets less liabilities)2022-12-31$2,689,465
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$2,809,746
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2022-12-31$2,565,319
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2022-12-31$2,757,223
Interest on participant loans2022-12-31$3,039
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2022-12-31$61,864
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2022-12-31$17,007
Net investment gain/loss from registered investment companies (e.g. mutual funds)2022-12-31$-589,647
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$129,337
Employer contributions (assets) at beginning of year2022-12-31$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-12-31$107,084
Contract administrator fees2022-12-31$2,102
Did the plan have assets held for investment2022-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2022-12-31410746749
2021 : POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$0
Total income from all sources (including contributions)2021-12-31$737,670
Total loss/gain on sale of assets2021-12-31$0
Total of all expenses incurred2021-12-31$23,492
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$21,442
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$461,877
Value of total assets at end of year2021-12-31$2,809,746
Value of total assets at beginning of year2021-12-31$2,095,568
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$2,050
Total interest from all sources2021-12-31$2,338
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$300,000
If this is an individual account plan, was there a blackout period2021-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2021-12-31$0
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$326,738
Participant contributions at end of year2021-12-31$35,516
Participant contributions at beginning of year2021-12-31$33,679
Income. Received or receivable in cash from other sources (including rollovers)2021-12-31$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$714,178
Value of net assets at end of year (total assets less liabilities)2021-12-31$2,809,746
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$2,095,568
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2021-12-31$2,757,223
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2021-12-31$2,029,860
Interest on participant loans2021-12-31$1,985
Interest earned on other investments2021-12-31$353
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year2021-12-31$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year2021-12-31$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2021-12-31$17,007
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2021-12-31$32,029
Net investment gain/loss from registered investment companies (e.g. mutual funds)2021-12-31$273,455
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$135,139
Employer contributions (assets) at end of year2021-12-31$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$21,442
Contract administrator fees2021-12-31$2,050
Did the plan have assets held for investment2021-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2021-12-31410746749
2020 : POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$0
Total income from all sources (including contributions)2020-12-31$676,265
Total loss/gain on sale of assets2020-12-31$0
Total of all expenses incurred2020-12-31$38,262
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$37,345
Expenses. Certain deemed distributions of participant loans2020-12-31$0
Value of total corrective distributions2020-12-31$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$400,437
Value of total assets at end of year2020-12-31$2,095,568
Value of total assets at beginning of year2020-12-31$1,457,565
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$917
Total interest from all sources2020-12-31$2,313
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$145,757
If this is an individual account plan, was there a blackout period2020-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2020-12-31$0
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$253,343
Participant contributions at end of year2020-12-31$33,679
Participant contributions at beginning of year2020-12-31$20,024
Income. Received or receivable in cash from other sources (including rollovers)2020-12-31$46,448
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$638,003
Value of net assets at end of year (total assets less liabilities)2020-12-31$2,095,568
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$1,457,565
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2020-12-31$2,029,860
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2020-12-31$1,417,592
Interest on participant loans2020-12-31$1,911
Interest earned on other investments2020-12-31$402
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year2020-12-31$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2020-12-31$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2020-12-31$32,029
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2020-12-31$19,949
Net investment gain/loss from registered investment companies (e.g. mutual funds)2020-12-31$273,515
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31Yes
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$100,646
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$37,345
Contract administrator fees2020-12-31$917
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Disclaimer
Accountancy firm name2020-12-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2020-12-31410746749
2019 : POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$0
Total income from all sources (including contributions)2019-12-31$610,794
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$13,091
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$12,379
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$390,572
Value of total assets at end of year2019-12-31$1,457,565
Value of total assets at beginning of year2019-12-31$859,862
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$712
Total interest from all sources2019-12-31$1,401
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$20,000
If this is an individual account plan, was there a blackout period2019-12-31No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2019-12-31$0
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$270,072
Participant contributions at end of year2019-12-31$20,024
Participant contributions at beginning of year2019-12-31$16,107
Income. Received or receivable in cash from other sources (including rollovers)2019-12-31$3,361
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$597,703
Value of net assets at end of year (total assets less liabilities)2019-12-31$1,457,565
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$859,862
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2019-12-31$1,417,592
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2019-12-31$839,057
Interest on participant loans2019-12-31$1,186
Interest earned on other investments2019-12-31$215
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2019-12-31$19,949
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2019-12-31$4,698
Net investment gain/loss from registered investment companies (e.g. mutual funds)2019-12-31$218,821
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31Yes
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$117,139
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2019-12-31$12,379
Contract administrator fees2019-12-31$712
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31Yes
Opinion of an independent qualified public accountant for this plan2019-12-31Disclaimer
Accountancy firm name2019-12-31CLIFTONLARSONALLEN LLP
Accountancy firm EIN2019-12-31410746749

Form 5500 Responses for POMONA COMMUNITY HEALTH CENTER 403(B) PLAN

2022: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: POMONA COMMUNITY HEALTH CENTER 403(B) PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberGAP-B2-KJ9W
Policy instance 1
Insurance contract or identification numberGAP-B2-KJ9W
Number of Individuals Covered16
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $167
Total amount of fees paid to insurance companyUSD $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 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?Yes
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 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
Commission paid to Insurance BrokerUSD $167
Insurance broker organization code?7
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberGAP-B2-KJ9W
Policy instance 1
Insurance contract or identification numberGAP-B2-KJ9W
Number of Individuals Covered14
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $113
Total amount of fees paid to insurance companyUSD $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 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?Yes
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 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
Commission paid to Insurance BrokerUSD $113
Insurance broker organization code?7
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberGAP-B2-KJ9W
Policy instance 1
Insurance contract or identification numberGAP-B2-KJ9W
Number of Individuals Covered200
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $103
Total amount of fees paid to insurance companyUSD $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 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?Yes
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 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
Commission paid to Insurance BrokerUSD $103
Insurance broker organization code?7
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract numberGAP-B2-KJ9W
Policy instance 1
Insurance contract or identification numberGAP-B2-KJ9W
Number of Individuals Covered16
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $51
Total amount of fees paid to insurance companyUSD $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 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?Yes
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 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
Commission paid to Insurance BrokerUSD $51
Amount paid for insurance broker fees0
Insurance broker organization code?7

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