PACIFIC SUNWEAR STORES LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PACIFIC SUNWEAR STORES LLC HEALTH AND WELFARE BENEFITS PLAN
| 2023: PACIFIC SUNWEAR STORES LLC HEALTH AND WELFARE BENEFITS PLAN 2023 form 5500 responses |
|---|
| 2023-06-01 | Type of plan entity | Single employer plan |
| 2023-06-01 | Plan funding arrangement – Insurance | Yes |
| 2023-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: PACIFIC SUNWEAR STORES LLC HEALTH AND WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PACIFIC SUNWEAR STORES LLC HEALTH AND WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX0980108 |
| Policy instance | 7 |
| Insurance contract or identification number | FLX0980108 | | Number of Individuals Covered | 1071 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $14,319 | | Total amount of fees paid to insurance company | USD $0 | | 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 $774,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) |
| Policy contract number | 55075 |
| Policy instance | 1 |
| Insurance contract or identification number | 55075 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $981 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,599 | | 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 | 234900 |
| Policy instance | 2 |
| Insurance contract or identification number | 234900 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $3,542 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $850,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003792 |
| Policy instance | 3 |
| Insurance contract or identification number | SP0003792 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $2,596 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | TELEHEALTH | | Welfare Benefit Premiums Paid to Carrier | USD $51,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9902453 |
| Policy instance | 4 |
| Insurance contract or identification number | 9902453 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2023-06-01 | | 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 $34 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $8,481 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802480 |
| Policy instance | 5 |
| Insurance contract or identification number | 802480 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $6,472 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $69,234 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN GENERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 39950 ) |
| Policy contract number | 9902453 |
| Policy instance | 6 |
| Insurance contract or identification number | 9902453 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2024-01-01 | | Insurance policy end date | 2024-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $5,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX0980108 |
| Policy instance | 7 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 606984 |
| Policy instance | 6 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802480 |
| Policy instance | 5 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9902453 |
| Policy instance | 4 |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003792 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 234900 |
| Policy instance | 2 |
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) |
| Policy contract number | 55075 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 234900 |
| Policy instance | 2 |
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
| Policy contract number | 2083400 |
| Policy instance | 3 |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003792 |
| Policy instance | 4 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9902453 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 802480 |
| Policy instance | 6 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX980108 |
| Policy instance | 7 |
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) |
| Policy contract number | 55075 |
| Policy instance | 1 |
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