LIFESTANCE HEALTH INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LIFESTANCE HEALTH & WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 5,460 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 6,388 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 63 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 6,451 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 2,914 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 4,762 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 33 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 300 |
| Total of all active and inactive participants | 2021-01-01 | 5,095 |
| 2020: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 875 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 2,642 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 20 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 2,662 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 502 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 564 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 564 |
| Number of employers contributing to the scheme | 2019-01-01 | 12 |
| 2018: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 502 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 502 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2022: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Mulitple employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Mulitple employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Mulitple employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Mulitple employer plan |
| 2019-01-01 | Submission has been amended | 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: LIFESTANCE HEALTH & WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | First time form 5500 has been submitted | 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 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 606569 |
| Policy instance | 4 |
| Insurance contract or identification number | 606569 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $146 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,786,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $146 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 60516 |
| Policy instance | 3 |
| Insurance contract or identification number | 60516 | | Number of Individuals Covered | 6388 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $376,656 | | Total amount of fees paid to insurance company | USD $29,496 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $3,091,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $376,656 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30078357 |
| Policy instance | 2 |
| Insurance contract or identification number | 30078357 | | Number of Individuals Covered | 3628 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,701 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $378,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,701 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9489 |
| Policy instance | 1 |
| Insurance contract or identification number | 9489 | | Number of Individuals Covered | 6334 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $60,192 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $60,192 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4012641 |
| Policy instance | 1 |
| Insurance contract or identification number | 4012641 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $601,887 | | Total amount of fees paid to insurance company | USD $108,076 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,054,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $315,767 | | Amount paid for insurance broker fees | 108076 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9488, 9489 |
| Policy instance | 2 |
| Insurance contract or identification number | 9488, 9489 | | Number of Individuals Covered | 2694 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $86,203 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,499 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30078357 |
| Policy instance | 3 |
| Insurance contract or identification number | 30078357 | | Number of Individuals Covered | 2581 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,544 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $236,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,935 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 60516 |
| Policy instance | 4 |
| Insurance contract or identification number | 60516 | | Number of Individuals Covered | 4895 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $115,288 | | Total amount of fees paid to insurance company | USD $22,635 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,152,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,481 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 21883 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 606569 |
| Policy instance | 5 |
| Insurance contract or identification number | 606569 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $21,450 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $431,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,661 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 234709 |
| Policy instance | 6 |
| Insurance contract or identification number | 234709 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $71,217 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,426,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,007 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 294940 |
| Policy instance | 7 |
| Insurance contract or identification number | 294940 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $25,425 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,734 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 606569 |
| Policy instance | 5 |
| Insurance contract or identification number | 606569 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $54,912 | | Total amount of fees paid to insurance company | USD $5,450 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,095,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,912 | | Amount paid for insurance broker fees | 5450 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 60516 |
| Policy instance | 4 |
| Insurance contract or identification number | 60516 | | Number of Individuals Covered | 2642 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $68,198 | | Total amount of fees paid to insurance company | USD $383 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $625,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62,562 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30078357 |
| Policy instance | 3 |
| Insurance contract or identification number | 30078357 | | Number of Individuals Covered | 1391 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,951 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $125,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,951 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9488/9489 |
| Policy instance | 2 |
| Insurance contract or identification number | 9488/9489 | | Number of Individuals Covered | 2072 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $19,363 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,363 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4012641 |
| Policy instance | 1 |
| Insurance contract or identification number | 4012641 | | Number of Individuals Covered | 1917 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $396,641 | | Total amount of fees paid to insurance company | USD $51,588 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,916,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $396,641 | | Amount paid for insurance broker fees | 51588 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4012641 |
| Policy instance | 1 |
| Insurance contract or identification number | 4012641 | | Number of Individuals Covered | 514 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $211,957 | | Total amount of fees paid to insurance company | USD $36,009 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,298,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $211,957 | | Amount paid for insurance broker fees | 36009 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9488/9489 |
| Policy instance | 2 |
| Insurance contract or identification number | 9488/9489 | | Number of Individuals Covered | 924 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $19,363 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,363 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30078357 |
| Policy instance | 3 |
| Insurance contract or identification number | 30078357 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,054 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,054 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 60516 |
| Policy instance | 4 |
| Insurance contract or identification number | 60516 | | Number of Individuals Covered | 875 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $31,638 | | Total amount of fees paid to insurance company | USD $3,731 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $316,383 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,638 | | Amount paid for insurance broker fees | 2601 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 60516 |
| Policy instance | 4 |
| Insurance contract or identification number | 60516 | | Number of Individuals Covered | 502 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $11,560 | | Total amount of fees paid to insurance company | USD $147 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $115,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,903 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30078357 |
| Policy instance | 3 |
| Insurance contract or identification number | 30078357 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,314 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $740 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9488 |
| Policy instance | 2 |
| Insurance contract or identification number | 9488 | | Number of Individuals Covered | 458 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,442 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,382 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4012641 |
| Policy instance | 1 |
| Insurance contract or identification number | 4012641 | | Number of Individuals Covered | 387 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $84,799 | | Total amount of fees paid to insurance company | USD $11,236 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,119,971 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,113 | | Amount paid for insurance broker fees | 11236 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
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