BUNGIE, INC. has sponsored the creation of one or more 401k plans.
Additional information about BUNGIE, INC.
Submission information for form 5500 for 401k plan GROUP MEDICAL, DENTAL AND VISION PLAN
| Measure | Date | Value |
|---|
| 2022: GROUP MEDICAL, DENTAL AND VISION PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 1,214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 1,422 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 1,422 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| 2021: GROUP MEDICAL, DENTAL AND VISION PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 845 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 1,186 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 1,186 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: GROUP MEDICAL, DENTAL AND VISION PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 735 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 811 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 811 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: GROUP MEDICAL, DENTAL AND VISION PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 639 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 670 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 670 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: GROUP MEDICAL, DENTAL AND VISION PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 685 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 639 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 639 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: GROUP MEDICAL, DENTAL AND VISION PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 692 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 689 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 689 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: GROUP MEDICAL, DENTAL AND VISION PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 643 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 702 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 702 |
| 2015: GROUP MEDICAL, DENTAL AND VISION PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 569 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 643 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 643 |
| 2014: GROUP MEDICAL, DENTAL AND VISION PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 520 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 569 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 569 |
| 2013: GROUP MEDICAL, DENTAL AND VISION PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 451 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 514 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 520 |
| 2012: GROUP MEDICAL, DENTAL AND VISION PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 337 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 451 |
| Number of retired or separated participants receiving benefits | 2012-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
| Total of all active and inactive participants | 2012-10-01 | 451 |
| 2011: GROUP MEDICAL, DENTAL AND VISION PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 232 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 337 |
| Total of all active and inactive participants | 2011-10-01 | 337 |
| 2009: GROUP MEDICAL, DENTAL AND VISION PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 168 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 196 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-10-01 | 0 |
| Total of all active and inactive participants | 2009-10-01 | 196 |
| 2022: GROUP MEDICAL, DENTAL AND VISION PLAN 2022 form 5500 responses |
|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: GROUP MEDICAL, DENTAL AND VISION PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: GROUP MEDICAL, DENTAL AND VISION PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: GROUP MEDICAL, DENTAL AND VISION PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: GROUP MEDICAL, DENTAL AND VISION PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: GROUP MEDICAL, DENTAL AND VISION PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: GROUP MEDICAL, DENTAL AND VISION PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: GROUP MEDICAL, DENTAL AND VISION PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: GROUP MEDICAL, DENTAL AND VISION PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | Yes |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: GROUP MEDICAL, DENTAL AND VISION PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: GROUP MEDICAL, DENTAL AND VISION PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: GROUP MEDICAL, DENTAL AND VISION PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: GROUP MEDICAL, DENTAL AND VISION PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | SA2890LF088901 |
| Policy instance | 3 |
| Insurance contract or identification number | SA2890LF088901 | | Number of Individuals Covered | 2819 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $42,375 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $502,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 42375 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 2 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 1426 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $3,546 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $166,184 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,546 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4015706 |
| Policy instance | 1 |
| Insurance contract or identification number | 4015706 | | Number of Individuals Covered | 2788 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $386,807 | | Total amount of fees paid to insurance company | USD $183,662 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,349,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $386,807 | | Amount paid for insurance broker fees | 183662 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 232406 |
| Policy instance | 3 |
| Insurance contract or identification number | 232406 | | Number of Individuals Covered | 1161 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,828 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $493,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 17828 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 2 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 1175 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,191 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $132,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,191 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4015706 |
| Policy instance | 1 |
| Insurance contract or identification number | 4015706 | | Number of Individuals Covered | 2253 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $411,393 | | Total amount of fees paid to insurance company | USD $125,835 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,835,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $411,393 | | Amount paid for insurance broker fees | 125835 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 232406 |
| Policy instance | 3 |
| Insurance contract or identification number | 232406 | | Number of Individuals Covered | 811 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $9,095 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $459,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 9095 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 2 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 842 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $2,508 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $103,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,508 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4015706 |
| Policy instance | 1 |
| Insurance contract or identification number | 4015706 | | Number of Individuals Covered | 1685 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $86,884 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,223,032 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 86884 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 232406 |
| Policy instance | 3 |
| Insurance contract or identification number | 232406 | | Number of Individuals Covered | 733 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,308 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $363,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 5308 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 2 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 745 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $2,308 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,308 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4015706 |
| Policy instance | 1 |
| Insurance contract or identification number | 4015706 | | Number of Individuals Covered | 1523 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $235,581 | | Total amount of fees paid to insurance company | USD $56,818 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,916,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $235,581 | | Amount paid for insurance broker fees | 56818 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 232406 |
| Policy instance | 3 |
| Insurance contract or identification number | 232406 | | Number of Individuals Covered | 639 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,383 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $323,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 7383 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 2 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 654 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,287 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,333 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,287 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4015706 |
| Policy instance | 1 |
| Insurance contract or identification number | 4015706 | | Number of Individuals Covered | 1423 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $196,772 | | Total amount of fees paid to insurance company | USD $48,514 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,603,579 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $196,772 | | Amount paid for insurance broker fees | 48514 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 232406 |
| Policy instance | 4 |
| Insurance contract or identification number | 232406 | | Number of Individuals Covered | 688 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $4,061 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $296,250 | | 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: 53031 ) |
| Policy contract number | 30015876 |
| Policy instance | 3 |
| Insurance contract or identification number | 30015876 | | Number of Individuals Covered | 693 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,206 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,745 | | 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 number | 00649 |
| Policy instance | 2 |
| Insurance contract or identification number | 00649 | | Number of Individuals Covered | 695 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $62,214 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 804378 |
| Policy instance | 1 |
| Insurance contract or identification number | 804378 | | Number of Individuals Covered | 1542 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $258,282 | | Total amount of fees paid to insurance company | USD $44,818 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,062,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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