PAYLESS SHOE SOURCE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN
| 2023: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single 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 benefit arrangement – Insurance | Yes |
| 2020: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 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: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PAYLESS SHOE SOURCE EMPLOYEE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | Yes |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 930708 |
| Policy instance | 2 |
| Insurance contract or identification number | 930708 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $811,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | ADDN01172013 |
| Policy instance | 1 |
| Insurance contract or identification number | ADDN01172013 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $7,706 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $22,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 170968 |
| Policy instance | 3 |
| Insurance contract or identification number | 170968 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $28,334 | | Total amount of fees paid to insurance company | USD $3,929 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $23,144 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | N01172013 |
| Policy instance | 2 |
| Insurance contract or identification number | N01172013 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $12,936 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $36,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BMZV |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BMZV | | Number of Individuals Covered | 92 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,978 | | Total amount of fees paid to insurance company | USD $14,301 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT,CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $133,516 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF KANSAS (National Association of Insurance Commissioners NAIC id number: 70729 ) |
| Policy contract number | 658923135 |
| Policy instance | 3 |
| Insurance contract or identification number | 658923135 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5392784 |
| Policy instance | 1 |
| Insurance contract or identification number | 5392784 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,714 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BMZV |
| Policy instance | 1 |
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | N01172013 |
| Policy instance | 3 |
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 53946,53947 |
| Policy instance | 2 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0920619 |
| Policy instance | 1 |
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 53946,47 |
| Policy instance | 2 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921685 |
| Policy instance | 15 |
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10113 |
| Policy instance | 14 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0154468 |
| Policy instance | 6 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAN |
| Policy instance | 13 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAU |
| Policy instance | 12 |
| SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
| Policy contract number | 0154468 |
| Policy instance | 11 |
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 0154468 |
| Policy instance | 10 |
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 90214* |
| Policy instance | 9 |
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144820* |
| Policy instance | 8 |
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 ) |
| Policy contract number | 144818* |
| Policy instance | 7 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921693 |
| Policy instance | 16 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921701 |
| Policy instance | 17 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0866388-0868261 |
| Policy instance | 30 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0866388-0866390 |
| Policy instance | 29 |
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35594 |
| Policy instance | 27 |
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 19482 |
| Policy instance | 26 |
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 71075-4 |
| Policy instance | 25 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755616 |
| Policy instance | 24 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339133 |
| Policy instance | 23 |
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | 021235300* |
| Policy instance | 21 |
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 76828 |
| Policy instance | 20 |
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 10117641 |
| Policy instance | 19 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9927773 |
| Policy instance | 18 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30042727 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0866388 |
| Policy instance | 4 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 2499875 |
| Policy instance | 22 |
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8115200 |
| Policy instance | 28 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 20309 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 106320 |
| Policy instance | 2 |
| TAKECARE (National Association of Insurance Commissioners NAIC id number: 0466 ) |
| Policy contract number | PAYSHOE1 |
| Policy instance | 3 |
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 71075-4 |
| Policy instance | 29 |
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35594 |
| Policy instance | 31 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921693 |
| Policy instance | 19 |
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 19482 |
| Policy instance | 30 |
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 8115200 |
| Policy instance | 33 |
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 0154468 |
| Policy instance | 12 |
| SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 ) |
| Policy contract number | 0154468 |
| Policy instance | 11 |
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 90214* |
| Policy instance | 10 |
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144820* |
| Policy instance | 9 |
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 ) |
| Policy contract number | 144818* |
| Policy instance | 8 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755616 |
| Policy instance | 28 |
| SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
| Policy contract number | 0154468 |
| Policy instance | 13 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339133 |
| Policy instance | 27 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAU |
| Policy instance | 14 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAN |
| Policy instance | 15 |
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10113 |
| Policy instance | 16 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22605 |
| Policy instance | 17 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921685 |
| Policy instance | 18 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921701 |
| Policy instance | 20 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9927773 |
| Policy instance | 21 |
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 117641 |
| Policy instance | 22 |
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 76828 |
| Policy instance | 23 |
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | 021235300 |
| Policy instance | 24 |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003586 |
| Policy instance | 25 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 2499875 |
| Policy instance | 26 |
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144821* |
| Policy instance | 7 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0154468 |
| Policy instance | 6 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 50035 |
| Policy instance | 32 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 20309 |
| Policy instance | 1 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 106320 |
| Policy instance | 2 |
| TAKECARE (National Association of Insurance Commissioners NAIC id number: 0466 ) |
| Policy contract number | PAYSHOE1 |
| Policy instance | 3 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0866388 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30042727 |
| Policy instance | 5 |
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 90214* |
| Policy instance | 10 |
| SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 ) |
| Policy contract number | 0154468 |
| Policy instance | 11 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 96632041001 |
| Policy instance | 12 |
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 0154468 |
| Policy instance | 13 |
| SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
| Policy contract number | 0154468 |
| Policy instance | 14 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAU |
| Policy instance | 15 |
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144820* |
| Policy instance | 9 |
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 ) |
| Policy contract number | 144818* |
| Policy instance | 8 |
| HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 144821* |
| Policy instance | 7 |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0154468 |
| Policy instance | 6 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30042727 |
| Policy instance | 5 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0866388 |
| Policy instance | 4 |
| TAKECARE (National Association of Insurance Commissioners NAIC id number: 0466 ) |
| Policy contract number | PAYSHOE1 |
| Policy instance | 3 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 106320 |
| Policy instance | 2 |
| DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 ) |
| Policy contract number | 14RMBAN |
| Policy instance | 16 |
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10113 |
| Policy instance | 17 |
| KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
| Policy contract number | 22605 |
| Policy instance | 18 |
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35594 |
| Policy instance | 32 |
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 19482 |
| Policy instance | 31 |
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 71075-4 |
| Policy instance | 30 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755616 |
| Policy instance | 29 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339133 |
| Policy instance | 28 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 2499875 |
| Policy instance | 27 |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0003586 |
| Policy instance | 26 |
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | 021235300 |
| Policy instance | 25 |
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 ) |
| Policy contract number | 76828 |
| Policy instance | 24 |
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 117641 |
| Policy instance | 23 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9927773 |
| Policy instance | 22 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921701 |
| Policy instance | 21 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921693 |
| Policy instance | 20 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9921685 |
| Policy instance | 19 |
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 20309 |
| Policy instance | 1 |
