PEG LION, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND
401k plan membership statisitcs for RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND
| Measure | Date | Value |
|---|
| 2022 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2022 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $1,355,556 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $1,594,956 |
| Total income from all sources (including contributions) | 2022-12-31 | $8,733,287 |
| Total of all expenses incurred | 2022-12-31 | $8,700,149 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $7,945,103 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $8,733,287 |
| Value of total assets at end of year | 2022-12-31 | $2,044,044 |
| Value of total assets at beginning of year | 2022-12-31 | $2,250,306 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $755,046 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Administrative expenses professional fees incurred | 2022-12-31 | $331,580 |
| Was this plan covered by a fidelity bond | 2022-12-31 | Yes |
| Value of fidelity bond cover | 2022-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Contributions received from participants | 2022-12-31 | $3,080 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $5,428 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $2,454 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-12-31 | $1,337,172 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-12-31 | $1,590,451 |
| Administrative expenses (other) incurred | 2022-12-31 | $167,941 |
| Liabilities. Value of operating payables at end of year | 2022-12-31 | $18,384 |
| Liabilities. Value of operating payables at beginning of year | 2022-12-31 | $4,505 |
| Total non interest bearing cash at end of year | 2022-12-31 | $1,371,505 |
| Total non interest bearing cash at beginning of year | 2022-12-31 | $1,456,395 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $33,138 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $688,488 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $655,350 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Value of interest in pooled separate accounts at end of year | 2022-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $7,945,103 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $8,730,207 |
| Employer contributions (assets) at end of year | 2022-12-31 | $667,111 |
| Employer contributions (assets) at beginning of year | 2022-12-31 | $791,457 |
| Contract administrator fees | 2022-12-31 | $255,525 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-12-31 | No |
| Did the plan have assets held for investment | 2022-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | RBTK, LLP |
| Accountancy firm EIN | 2022-12-31 | 330567239 |
| 2021 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2021 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $1,594,956 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $1,542,606 |
| Total income from all sources (including contributions) | 2021-12-31 | $10,029,775 |
| Total of all expenses incurred | 2021-12-31 | $10,056,819 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $9,167,078 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $10,004,994 |
| Value of total assets at end of year | 2021-12-31 | $2,250,306 |
| Value of total assets at beginning of year | 2021-12-31 | $2,225,000 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $889,741 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Administrative expenses professional fees incurred | 2021-12-31 | $381,607 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $51,813 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $2,454 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $989 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $1,590,451 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-12-31 | $1,528,897 |
| Other income not declared elsewhere | 2021-12-31 | $24,781 |
| Administrative expenses (other) incurred | 2021-12-31 | $198,798 |
| Liabilities. Value of operating payables at end of year | 2021-12-31 | $4,505 |
| Liabilities. Value of operating payables at beginning of year | 2021-12-31 | $13,709 |
| Total non interest bearing cash at end of year | 2021-12-31 | $1,456,395 |
| Total non interest bearing cash at beginning of year | 2021-12-31 | $1,459,568 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $-27,044 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $655,350 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $682,394 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Value of interest in pooled separate accounts at end of year | 2021-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $9,167,078 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $9,953,181 |
| Employer contributions (assets) at end of year | 2021-12-31 | $791,457 |
| Employer contributions (assets) at beginning of year | 2021-12-31 | $764,443 |
| Contract administrator fees | 2021-12-31 | $309,336 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-12-31 | No |
| Did the plan have assets held for investment | 2021-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | RBTK, LLP |
| Accountancy firm EIN | 2021-12-31 | 330567239 |
| 2020 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2020 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $1,542,606 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $2,005,879 |
| Total income from all sources (including contributions) | 2020-12-31 | $10,354,350 |
| Total of all expenses incurred | 2020-12-31 | $10,150,810 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $9,290,169 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $10,322,824 |
| Value of total assets at end of year | 2020-12-31 | $2,225,000 |
| Value of total assets at beginning of year | 2020-12-31 | $2,484,733 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $860,641 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Administrative expenses professional fees incurred | 2020-12-31 | $387,266 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Contributions received from participants | 2020-12-31 | $44,865 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $989 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $2,032 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-12-31 | $1,528,897 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-12-31 | $1,992,250 |
| Other income not declared elsewhere | 2020-12-31 | $31,526 |
| Administrative expenses (other) incurred | 2020-12-31 | $159,330 |
| Liabilities. Value of operating payables at end of year | 2020-12-31 | $13,709 |
| Liabilities. Value of operating payables at beginning of year | 2020-12-31 | $13,629 |
| Total non interest bearing cash at end of year | 2020-12-31 | $1,459,568 |
| Total non interest bearing cash at beginning of year | 2020-12-31 | $1,478,303 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $203,540 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $682,394 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $478,854 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Value of interest in pooled separate accounts at end of year | 2020-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $9,290,169 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $10,277,959 |
| Employer contributions (assets) at end of year | 2020-12-31 | $764,443 |
| Employer contributions (assets) at beginning of year | 2020-12-31 | $1,004,398 |
| Contract administrator fees | 2020-12-31 | $314,045 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-12-31 | No |
| Did the plan have assets held for investment | 2020-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | RBTK, LLP |
| Accountancy firm EIN | 2020-12-31 | 330567239 |
| 2019 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2019 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $2,005,879 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $1,453,327 |
| Total income from all sources (including contributions) | 2019-12-31 | $10,536,891 |
| Total of all expenses incurred | 2019-12-31 | $10,409,563 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $9,433,589 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $10,536,891 |
| Value of total assets at end of year | 2019-12-31 | $2,484,733 |
| Value of total assets at beginning of year | 2019-12-31 | $1,804,853 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $975,974 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Administrative expenses professional fees incurred | 2019-12-31 | $55,413 |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $12,595 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2019-12-31 | $10,390 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $2,032 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $2,017 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $1,992,250 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $1,435,382 |
| Administrative expenses (other) incurred | 2019-12-31 | $591,442 |
| Liabilities. Value of operating payables at end of year | 2019-12-31 | $13,629 |
| Liabilities. Value of operating payables at beginning of year | 2019-12-31 | $17,945 |
| Total non interest bearing cash at end of year | 2019-12-31 | $1,478,303 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $1,112,716 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $127,328 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $478,854 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $351,526 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Value of interest in pooled separate accounts at end of year | 2019-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $9,433,589 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $10,513,906 |
| Employer contributions (assets) at end of year | 2019-12-31 | $1,004,398 |
| Employer contributions (assets) at beginning of year | 2019-12-31 | $690,120 |
| Contract administrator fees | 2019-12-31 | $329,119 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2019-12-31 | No |
| Did the plan have assets held for investment | 2019-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Accountancy firm name | 2019-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2019-12-31 | 952076568 |
| 2018 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2018 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $1,453,327 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $1,248,447 |
| Total income from all sources (including contributions) | 2018-12-31 | $8,022,482 |
| Total of all expenses incurred | 2018-12-31 | $7,979,021 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $7,286,251 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $8,022,482 |
| Value of total assets at end of year | 2018-12-31 | $1,804,853 |
| Value of total assets at beginning of year | 2018-12-31 | $1,556,512 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $692,770 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Administrative expenses professional fees incurred | 2018-12-31 | $78,483 |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Contributions received from participants | 2018-12-31 | $34,300 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2018-12-31 | $2,222 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $2,017 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $1,834 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2018-12-31 | $1,435,382 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2018-12-31 | $1,244,892 |
| Administrative expenses (other) incurred | 2018-12-31 | $372,326 |
| Liabilities. Value of operating payables at end of year | 2018-12-31 | $17,945 |
| Liabilities. Value of operating payables at beginning of year | 2018-12-31 | $3,555 |
| Total non interest bearing cash at end of year | 2018-12-31 | $1,112,716 |
| Total non interest bearing cash at beginning of year | 2018-12-31 | $947,429 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $43,461 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $351,526 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $308,065 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Value of interest in pooled separate accounts at end of year | 2018-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $7,286,251 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $7,985,960 |
| Employer contributions (assets) at end of year | 2018-12-31 | $690,120 |
| Employer contributions (assets) at beginning of year | 2018-12-31 | $607,249 |
| Contract administrator fees | 2018-12-31 | $241,961 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-12-31 | No |
| Did the plan have assets held for investment | 2018-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
| Accountancy firm name | 2018-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2018-12-31 | 952076568 |
| 2017 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2017 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $1,248,447 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $1,315,446 |
| Total income from all sources (including contributions) | 2017-12-31 | $8,106,860 |
| Total of all expenses incurred | 2017-12-31 | $8,015,649 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $7,356,717 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $8,106,860 |
| Value of total assets at end of year | 2017-12-31 | $1,556,512 |
| Value of total assets at beginning of year | 2017-12-31 | $1,532,300 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $658,932 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Administrative expenses professional fees incurred | 2017-12-31 | $52,650 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Contributions received from participants | 2017-12-31 | $28,192 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2017-12-31 | $4,649 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $1,834 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $1,528 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2017-12-31 | $1,244,892 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2017-12-31 | $1,299,892 |
| Administrative expenses (other) incurred | 2017-12-31 | $358,382 |
| Liabilities. Value of operating payables at end of year | 2017-12-31 | $3,555 |
| Liabilities. Value of operating payables at beginning of year | 2017-12-31 | $15,554 |
| Total non interest bearing cash at end of year | 2017-12-31 | $947,429 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $877,382 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $91,211 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $308,065 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $216,854 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Value of interest in common/collective trusts at end of year | 2017-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $7,356,717 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $8,074,019 |
| Employer contributions (assets) at end of year | 2017-12-31 | $607,249 |
| Employer contributions (assets) at beginning of year | 2017-12-31 | $653,390 |
| Contract administrator fees | 2017-12-31 | $247,900 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-12-31 | No |
| Did the plan have assets held for investment | 2017-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2017-12-31 | 952076568 |
| 2016 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2016 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $1,315,446 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $1,256,098 |
| Total income from all sources (including contributions) | 2016-12-31 | $7,955,215 |
| Total of all expenses incurred | 2016-12-31 | $7,876,059 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $7,215,616 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $7,955,215 |
| Value of total assets at end of year | 2016-12-31 | $1,532,300 |
| Value of total assets at beginning of year | 2016-12-31 | $1,393,796 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $660,443 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Administrative expenses professional fees incurred | 2016-12-31 | $62,150 |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Contributions received from participants | 2016-12-31 | $28,387 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2016-12-31 | $4,628 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-12-31 | $1,528 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $2,263 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $1,299,892 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $1,212,980 |
| Administrative expenses (other) incurred | 2016-12-31 | $349,743 |
| Liabilities. Value of operating payables at end of year | 2016-12-31 | $15,554 |
| Liabilities. Value of operating payables at beginning of year | 2016-12-31 | $43,118 |
| Total non interest bearing cash at end of year | 2016-12-31 | $877,382 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $749,486 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $79,156 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $216,854 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $137,698 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Value of interest in common/collective trusts at end of year | 2016-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $7,215,616 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $7,922,200 |
| Employer contributions (assets) at end of year | 2016-12-31 | $653,390 |
| Employer contributions (assets) at beginning of year | 2016-12-31 | $642,047 |
| Contract administrator fees | 2016-12-31 | $248,550 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Unqualified |
| Accountancy firm name | 2016-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2016-12-31 | 952076568 |
| 2015 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2015 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $1,256,098 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $1,231,243 |
| Total income from all sources (including contributions) | 2015-12-31 | $7,534,869 |
| Total of all expenses incurred | 2015-12-31 | $7,470,652 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $6,877,896 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $7,534,869 |
| Value of total assets at end of year | 2015-12-31 | $1,393,796 |
| Value of total assets at beginning of year | 2015-12-31 | $1,304,724 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $592,756 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Administrative expenses professional fees incurred | 2015-12-31 | $42,000 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $15,481 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2015-12-31 | $4,373 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $2,263 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $1,560 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2015-12-31 | $1,212,980 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2015-12-31 | $1,228,051 |
| Administrative expenses (other) incurred | 2015-12-31 | $312,935 |
| Liabilities. Value of operating payables at end of year | 2015-12-31 | $43,118 |
| Liabilities. Value of operating payables at beginning of year | 2015-12-31 | $3,192 |
| Total non interest bearing cash at end of year | 2015-12-31 | $749,486 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $712,923 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $64,217 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $137,698 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $73,481 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Value of interest in common/collective trusts at end of year | 2015-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $6,877,896 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $7,515,015 |
| Employer contributions (assets) at end of year | 2015-12-31 | $642,047 |
| Employer contributions (assets) at beginning of year | 2015-12-31 | $590,241 |
| Contract administrator fees | 2015-12-31 | $237,821 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2015-12-31 | 952076568 |
| 2014 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2014 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $1,231,243 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $1,528,948 |
| Total income from all sources (including contributions) | 2014-12-31 | $8,894,874 |
| Total of all expenses incurred | 2014-12-31 | $8,819,397 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $8,428,303 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $8,894,874 |
| Value of total assets at end of year | 2014-12-31 | $1,304,724 |
| Value of total assets at beginning of year | 2014-12-31 | $1,526,952 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $391,094 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Administrative expenses professional fees incurred | 2014-12-31 | $42,000 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $500,000 |
| If this is an individual account plan, was there a blackout period | 2014-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Contributions received from participants | 2014-12-31 | $33,533 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-12-31 | $1,560 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-12-31 | $1,309 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-12-31 | $1,228,051 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-12-31 | $1,513,446 |
| Administrative expenses (other) incurred | 2014-12-31 | $88,330 |
| Liabilities. Value of operating payables at end of year | 2014-12-31 | $3,192 |
| Liabilities. Value of operating payables at beginning of year | 2014-12-31 | $15,502 |
| Total non interest bearing cash at end of year | 2014-12-31 | $712,923 |
| Total non interest bearing cash at beginning of year | 2014-12-31 | $761,123 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $75,477 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $73,481 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $-1,996 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Value of interest in common/collective trusts at end of year | 2014-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $8,428,303 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $8,861,341 |
| Employer contributions (assets) at end of year | 2014-12-31 | $590,241 |
| Employer contributions (assets) at beginning of year | 2014-12-31 | $764,520 |
| Contract administrator fees | 2014-12-31 | $260,764 |
| Did the plan have assets held for investment | 2014-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Unqualified |
| Accountancy firm name | 2014-12-31 | LEAF & COLE, LLP |
| Accountancy firm EIN | 2014-12-31 | 952076568 |
| 2013 : RESTAURANT INDUSTRY HEALTH & WELFARE TRUST FUND 2013 401k financial data |
|---|
| Total plan liabilities at end of year | 2013-12-31 | $1,528,948 |
| Total income from all sources | 2013-12-31 | $7,876,770 |
| Expenses. Total of all expenses incurred | 2013-12-31 | $7,878,766 |
| Benefits paid (including direct rollovers) | 2013-12-31 | $7,597,776 |
| Total plan assets at end of year | 2013-12-31 | $1,526,952 |
| Value of fidelity bond covering the plan | 2013-12-31 | $500,000 |
| Total contributions received or receivable from participants | 2013-12-31 | $27,622 |
| Expenses. Other expenses not covered elsewhere | 2013-12-31 | $280,990 |
| Net income (gross income less expenses) | 2013-12-31 | $-1,996 |
| Net plan assets at end of year (total assets less liabilities) | 2013-12-31 | $-1,996 |
| Total contributions received or receivable from employer(s) | 2013-12-31 | $7,849,148 |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 184751 |
| Policy instance | 9 |
| Insurance contract or identification number | VG 184751 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Other welfare benefits provided | BASIC AND DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $14,295 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 1 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 536 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $992,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 277860 |
| Policy instance | 3 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $559,853 | | 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: 0000 ) |
| Policy contract number | 603578 |
| Policy instance | 4 |
| Insurance contract or identification number | 603578 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,167,994 | | 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: 0000 ) |
| Policy contract number | 231009 |
| Policy instance | 5 |
| Insurance contract or identification number | 231009 | | Number of Individuals Covered | 934 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,921,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 6 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 749 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $1,178 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $301,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,178 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 153826 |
| Policy instance | 7 |
| Insurance contract or identification number | GL 153826 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Other welfare benefits provided | BASIC LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $25,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206503 |
| Policy instance | 8 |
| Insurance contract or identification number | VAR 206503 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $65 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 1 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 591 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,076,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 277860 |
| Policy instance | 3 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $705,715 | | 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: 0000 ) |
| Policy contract number | 603578 |
| Policy instance | 4 |
| Insurance contract or identification number | 603578 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of fees paid to insurance company | USD $6,154 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,527,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6154 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 231009 |
| Policy instance | 5 |
| Insurance contract or identification number | 231009 | | Number of Individuals Covered | 862 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-01 | | Total amount of fees paid to insurance company | USD $13,379 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,445,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13379 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 6 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 806 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $318,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 153826 |
| Policy instance | 7 |
| Insurance contract or identification number | GL 153826 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Other welfare benefits provided | GROUP LIF AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $66,410 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 206503 |
| Policy instance | 8 |
| Insurance contract or identification number | VAR 206503 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 184751 |
| Policy instance | 9 |
| Insurance contract or identification number | VG 184751 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Other welfare benefits provided | VOLUNTARY GROUP TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $26,284 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 1 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 565 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-28 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,232,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 277860 |
| Policy instance | 3 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $721,545 | | 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: 0000 ) |
| Policy contract number | 231009 |
| Policy instance | 5 |
| Insurance contract or identification number | 231009 | | Number of Individuals Covered | 832 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-01 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,052,492 | | 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: 0000 ) |
| Policy contract number | 603578 |
| Policy instance | 4 |
| Insurance contract or identification number | 603578 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-28 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,476,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 6 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 702 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-28 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $290,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 153826 |
| Policy instance | 7 |
| Insurance contract or identification number | GL 153826 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $214 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,820 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 214 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 803 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,105,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VARIOUS |
| Policy instance | 4 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 225 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $600 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 600 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 5 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 706 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $294,039 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 529 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,953,013 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 516 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,042 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 521 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,175 | | 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: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 841 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of fees paid to insurance company | USD $746 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,132,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 746 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 5 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 739 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $337,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VARIOUS |
| Policy instance | 4 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 246 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of fees paid to insurance company | USD $89 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 89 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,731,967 | | 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: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 882 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,706,864 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,160,355 | | 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: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 1282 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $538 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,873 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $538 | | Additional information about fees paid to insurance broker | BASE COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VARIOUS |
| Policy instance | 4 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 220 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $387 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 387 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509233 |
| Policy instance | 5 |
| Insurance contract or identification number | 00509233 | | Number of Individuals Covered | 889 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $385,827 | | 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: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 567 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $21,697 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,485,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,697 | | Additional information about fees paid to insurance broker | BASE COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT BENEFITS INSURANCE OF SO CA |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $33,642 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,898,050 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,642 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT INS SERVICES OF SO CAL |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 542 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,956 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,203 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,956 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT SO CAL INSURANCE SERVICES |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5460062 |
| Policy instance | 4 |
| Insurance contract or identification number | 5460062 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $2,924 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,924 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT INS SERVICES OF SO CAL |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VARIOUS |
| Policy instance | 5 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 185 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2015-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 000JA708 |
| Policy instance | 6 |
| Insurance contract or identification number | 000JA708 | | Number of Individuals Covered | 766 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2015-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $292,184 | | 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: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 535 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $142,178 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,763,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $116,325 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT BENEFIT INS SERV OF SO CAL |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $154,869 | | Total amount of fees paid to insurance company | USD $10,945 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,004,127 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $154,869 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 10945 | | Additional information about fees paid to insurance broker | INCENTIVE, EDUCATION, COMMUNICATION AND TRAINING | | Insurance broker name | EDGEWOOD PARTNERS |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5457707/5460440 |
| Policy instance | 3 |
| Insurance contract or identification number | 5457707/5460440 | | Number of Individuals Covered | 901 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $28,421 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $550,558 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,929 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PAYMENT PROGRAM AND REIMBURSED EXPENSES | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT INS SERVICES OF SO CAL |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 4 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 874 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,520 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $95,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,213 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT SO CAL INSURANCE SERVICES |
|
| UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 ) |
| Policy contract number | 5457707 |
| Policy instance | 5 |
| Insurance contract or identification number | 5457707 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,438 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,201 | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT INS SERVICES OF SO CAL |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30025048 |
| Policy instance | 5 |
| Insurance contract or identification number | 30025048 | | Number of Individuals Covered | 906 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,653 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,986 | | Insurance broker name | LEAVITT INSURANCE AGENCY SAN DIEGO |
|
| PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 ) |
| Policy contract number | 97903-APEX |
| Policy instance | 4 |
| Insurance contract or identification number | 97903-APEX | | Number of Individuals Covered | 46 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $8,397 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,397 | | Insurance broker name | LEAVITT INSURANCE AGENCY SA DIEGO |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | VARIOUS |
| Policy instance | 3 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 1128 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $54,591 | | Total amount of fees paid to insurance company | USD $11,005 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $535,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,591 | | Amount paid for insurance broker fees | 11005 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PAYMENT PROGRAM AND REIMBURSED EXPENSES | | Insurance broker organization code? | 3 | | Insurance broker name | LEAVITT BENEFITS INSURANCE OF SO CA |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277860 |
| Policy instance | 2 |
| Insurance contract or identification number | 277860 | | Number of Individuals Covered | 506 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $138,078 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,829,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $138,078 | | Insurance broker name | LEAVITT BENEFIT INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 586 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $147,084 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,100,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $130,665 | | Insurance broker name | KRISTIN KAHLE |
|
