PBF HOLDING COMPANY LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN
| 2023: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan is a collectively bargained plan | Yes |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | Yes |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | Yes |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | Yes |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PBF HOLDING COMPANY LLC HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | First time form 5500 has been submitted | Yes |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 4 |
| Insurance contract or identification number | 6110025 | | Number of Individuals Covered | 1104 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $23,652 | | Total amount of fees paid to insurance company | USD $2,978 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $217,049 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 5 |
| Insurance contract or identification number | 8808314 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $13,415 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $61,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 606488 |
| Policy instance | 7 |
| Insurance contract or identification number | 606488 | | Number of Individuals Covered | 959 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,504,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | GTP 0009159558 |
| Policy instance | 8 |
| Insurance contract or identification number | GTP 0009159558 | | Number of Individuals Covered | 3574 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $18,817 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $125,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 0314818HNO | | Number of Individuals Covered | 296 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,344,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53316 |
| Policy instance | 2 |
| Insurance contract or identification number | 53316 | | Number of Individuals Covered | 3580 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $195,800 | | Total amount of fees paid to insurance company | USD $700 | | Health Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $6,789,775 | | 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 number | 30020495 |
| Policy instance | 3 |
| Insurance contract or identification number | 30020495 | | Number of Individuals Covered | 3310 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $7,285 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $642,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 0314818HNO | | Number of Individuals Covered | 283 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,954,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53316 |
| Policy instance | 2 |
| Insurance contract or identification number | 53316 | | Number of Individuals Covered | 3401 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $138,671 | | Total amount of fees paid to insurance company | USD $671 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,879,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 4 |
| Insurance contract or identification number | 6110025 | | Number of Individuals Covered | 1007 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $21,712 | | Total amount of fees paid to insurance company | USD $3,735 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $217,029 | | 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 number | 30020495 |
| Policy instance | 3 |
| Insurance contract or identification number | 30020495 | | Number of Individuals Covered | 3073 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,119 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $615,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 5 |
| Insurance contract or identification number | 8808314 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $11,906 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,901 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 606488 |
| Policy instance | 7 |
| Insurance contract or identification number | 606488 | | Number of Individuals Covered | 937 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,574,590 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | ADDN18158188 |
| Policy instance | 8 |
| Insurance contract or identification number | ADDN18158188 | | Number of Individuals Covered | 3401 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $18,791 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $125,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-1389 |
| Policy instance | 2 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53316 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 4 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 5 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 6 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 606488 |
| Policy instance | 8 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 606488 |
| Policy instance | 9 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-1389 |
| Policy instance | 2 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53316 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 4 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 7 |
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000021954 |
| Policy instance | 6 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 5 |
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000021954 |
| Policy instance | 6 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 5 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 4 |
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53316 |
| Policy instance | 3 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9907-1389 |
| Policy instance | 2 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 6 |
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95287 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 99071389 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 3 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 402787G |
| Policy instance | 4 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 8 |
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000021954 |
| Policy instance | 7 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 5 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 6110025 |
| Policy instance | 7 |
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000021954 |
| Policy instance | 8 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 9 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 99071389 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 3 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 402787G |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 5 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS08304 |
| Policy instance | 6 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 5 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 402787G |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 2 |
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 0314818HNO |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 1 |
| MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 ) |
| Policy contract number | 8808314 |
| Policy instance | 4 |
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 402787G |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 314818 |
| Policy instance | 2 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 1 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 314818 |
| Policy instance | 2 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 314818 |
| Policy instance | 2 |
| INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 ) |
| Policy contract number | 0001416637 |
| Policy instance | 3 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30020495 |
| Policy instance | 9 |
| AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 ) |
| Policy contract number | 0001416637 |
| Policy instance | 2 |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10138600 |
| Policy instance | 8 |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10102525 |
| Policy instance | 6 |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10102524 |
| Policy instance | 5 |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 40000100011823 |
| Policy instance | 4 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00459216 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 314818 |
| Policy instance | 1 |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10129968 |
| Policy instance | 7 |
