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| Plan Name | ANDEAVOR OMNIBUS GROUP WELFARE BENEFITS PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | ANDEAVOR LLC |
| Employer identification number (EIN): | 384084986 |
| NAIC Classification: | 324110 |
| NAIC Description: | Petroleum Refineries |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2019-01-01 | STEPHEN A. NELSON | 2020-07-11 | ||
| 501 | 2018-01-01 | STEPHEN A. NELSON | 2019-10-09 |
| 2019: ANDEAVOR OMNIBUS GROUP WELFARE BENEFITS PLAN 2019 form 5500 responses | ||
|---|---|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan is a collectively bargained plan | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ANDEAVOR OMNIBUS GROUP WELFARE BENEFITS PLAN 2018 form 5500 responses | ||
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan is a collectively bargained plan | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |
| Policy contract number | 221118 |
| Policy instance | 1 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |
| Policy contract number | 215616 |
| Policy instance | 2 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 228845 |
| Policy instance | 8 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |
| Policy contract number | 0216734 |
| Policy instance | 7 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX980435 |
| Policy instance | 6 |
| BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 ) | |
| Policy contract number | 28032 |
| Policy instance | 5 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) | |
| Policy contract number | 12059007 |
| Policy instance | 4 |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 9260017 |
| Policy instance | 3 |
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) | |
| Policy contract number | GF389046438201 |
| Policy instance | 2 |
| DEAR OAKS EAP SERVICES, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) | |
| Policy contract number | 00 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | FLX980423 |
| Policy instance | 9 |
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