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| Plan Name | PSEB LLC HEALTH AND WELFARE BENEFITS PLAN |
| Plan identification number | 513 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | PSEB LLC |
| Employer identification number (EIN): | 352509842 |
| NAIC Classification: | 454110 |
| NAIC Description: | Electronic Shopping and Mail-Order Houses |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 513 | 2020-06-01 | SANDY RENTERIA | 2021-11-15 | ||
| 513 | 2020-06-01 | GABY JIMENEZ | 2022-12-21 |
| 2020: PSEB LLC HEALTH AND WELFARE BENEFITS PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | First time form 5500 has been submitted | Yes |
| 2020-06-01 | Submission has been amended | Yes |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HAWAII MEDICAL ASSURANCE ASSOCIATION (National Association of Insurance Commissioners NAIC id number: 48330 ) | |
| Policy contract number | 55075 |
| Policy instance | 1 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) | |
| Policy contract number | 802480 |
| Policy instance | 6 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 9902453 |
| Policy instance | 5 |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) | |
| Policy contract number | SP0003792 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX980108 |
| 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 |
| GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) | |
| Policy contract number | 2083400 |
| 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 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX980108 |
| Policy instance | 7 |
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