DOCTOR CENTER HOSPITAL SJ has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: DCH SAN JUAN HEALTH 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 188 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 241 |
| Total of all active and inactive participants | 2022-02-01 | 241 |
| Total participants | 2022-02-01 | 241 |
| 2021: DCH SAN JUAN HEALTH 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 188 |
| Total of all active and inactive participants | 2021-02-01 | 188 |
| Total participants | 2021-02-01 | 188 |
| 2020: DCH SAN JUAN HEALTH 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 198 |
| Total of all active and inactive participants | 2020-02-01 | 198 |
| Total participants | 2020-02-01 | 198 |
| 2019: DCH SAN JUAN HEALTH 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 201 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 214 |
| Total of all active and inactive participants | 2019-02-01 | 214 |
| Total participants | 2019-02-01 | 214 |
| 2018: DCH SAN JUAN HEALTH 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 201 |
| Total of all active and inactive participants | 2018-02-01 | 201 |
| Total participants | 2018-02-01 | 201 |
| 2017: DCH SAN JUAN HEALTH 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 166 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 173 |
| Total of all active and inactive participants | 2017-02-01 | 173 |
| Total participants | 2017-02-01 | 173 |
| 2016: DCH SAN JUAN HEALTH 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 166 |
| Total of all active and inactive participants | 2016-12-01 | 166 |
| Total participants | 2016-12-01 | 166 |
| 2015: DCH SAN JUAN HEALTH 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 178 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 175 |
| Total of all active and inactive participants | 2015-12-01 | 175 |
| Total participants | 2015-12-01 | 175 |
| 2014: DCH SAN JUAN HEALTH 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 178 |
| Total of all active and inactive participants | 2014-12-01 | 178 |
| Total participants | 2014-12-01 | 178 |
| 2012: DCH SAN JUAN HEALTH 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 153 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 201 |
| Total of all active and inactive participants | 2012-12-01 | 201 |
| Total participants | 2012-12-01 | 201 |
| Total participants, beginning-of-year | 2012-11-01 | 162 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 153 |
| Total of all active and inactive participants | 2012-11-01 | 153 |
| Total participants | 2012-11-01 | 153 |
| 2011: DCH SAN JUAN HEALTH 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 162 |
| Total of all active and inactive participants | 2011-11-01 | 162 |
| Total participants | 2011-11-01 | 162 |
| 2010: DCH SAN JUAN HEALTH 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-11-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-11-01 | 200 |
| Total of all active and inactive participants | 2010-11-01 | 200 |
| Total participants | 2010-11-01 | 200 |
| 2009: DCH SAN JUAN HEALTH 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 185 |
| Total of all active and inactive participants | 2009-11-01 | 185 |
| Total participants | 2009-11-01 | 185 |
| 2008: DCH SAN JUAN HEALTH 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-11-01 | 185 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-11-01 | 185 |
| Total of all active and inactive participants | 2008-11-01 | 185 |
| Total participants | 2008-11-01 | 185 |
| 2022: DCH SAN JUAN HEALTH 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | No |
| 2022-02-01 | This submission is the final filing | No |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-02-01 | Plan is a collectively bargained plan | No |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: DCH SAN JUAN HEALTH 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Submission has been amended | No |
| 2021-02-01 | This submission is the final filing | No |
| 2021-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-02-01 | Plan is a collectively bargained plan | No |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: DCH SAN JUAN HEALTH 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | No |
| 2020-02-01 | This submission is the final filing | No |
| 2020-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-02-01 | Plan is a collectively bargained plan | No |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: DCH SAN JUAN HEALTH 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: DCH SAN JUAN HEALTH 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: DCH SAN JUAN HEALTH 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: DCH SAN JUAN HEALTH 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: DCH SAN JUAN HEALTH 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: DCH SAN JUAN HEALTH 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: DCH SAN JUAN HEALTH 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Submission has been amended | No |
| 2012-11-01 | This submission is the final filing | No |
| 2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-11-01 | Plan is a collectively bargained plan | No |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: DCH SAN JUAN HEALTH 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: DCH SAN JUAN HEALTH 2010 form 5500 responses |
|---|
| 2010-11-01 | Type of plan entity | Single employer plan |
| 2010-11-01 | Submission has been amended | No |
| 2010-11-01 | This submission is the final filing | No |
| 2010-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-11-01 | Plan is a collectively bargained plan | No |
| 2010-11-01 | Plan funding arrangement – Insurance | Yes |
| 2010-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: DCH SAN JUAN HEALTH 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | Submission has been amended | No |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-11-01 | Plan is a collectively bargained plan | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: DCH SAN JUAN HEALTH 2008 form 5500 responses |
|---|
| 2008-11-01 | Type of plan entity | Single employer plan |
| 2008-11-01 | First time form 5500 has been submitted | Yes |
| 2008-11-01 | Submission has been amended | No |
| 2008-11-01 | This submission is the final filing | No |
| 2008-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-11-01 | Plan is a collectively bargained plan | No |
| 2008-11-01 | Plan funding arrangement – Insurance | Yes |
| 2008-11-01 | Plan benefit arrangement – Insurance | Yes |
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0007415 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0007415 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $23,410 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | MAJOR MEDICAL, QUICKHELP, TELECONSULTA, ORGAN & TISSUE TRANSPLANT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,410 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 |
|
| MCS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60030 ) |
| Policy contract number | 79-791618 |
| Policy instance | 1 |
| Insurance contract or identification number | 79-791618 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $23,536 | | Total amount of fees paid to insurance company | USD $4,707 | | 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 | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,536 | | Amount paid for insurance broker fees | 4707 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $23,252 | | 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 | 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 | | Other welfare benefits provided | MAJOR MEDICAL, QUICKHELP, TELECONSULTA, ORGAN & TISSUE TRANSPLANT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,252 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $24,368 | | 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 | 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 | | Other welfare benefits provided | MAJOR MEDICAL, QUICKHELP, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,368 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $22,458 | | 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 | 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 | | Other welfare benefits provided | MAJOR MEDICAL, TELECONSULTA, ORGAN & TISSUE TRANSPLANT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,458 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $29,489 | | 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 | 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 | | Other welfare benefits provided | ORGAN TRANSPLANT & TELECONSULTA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,489 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | FEDELTA INSURANCE CORP. |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $24,843 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 | | Other welfare benefits provided | ORGAN AND TISSUE TRANSPLANT & TELECONSULTA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,843 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | FEDELTA INSURANCE CORP |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $24,224 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 | | Other welfare benefits provided | ORGAN AND TISSUE TRANSPLANT & TELECONSULTA | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $26,119 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | SP0004887 |
| Policy instance | 1 |
| Insurance contract or identification number | SP0004887 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $24,987 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,987 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | FEDELTA INSURANCE CORP |
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| PAN AMERICAN LIFE INSURANCE GROUP (National Association of Insurance Commissioners NAIC id number: 12952 ) |
| Policy contract number | 88575 |
| Policy instance | 1 |
| Insurance contract or identification number | 88575 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $1,644 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $1,644 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | FEDELTA INSURANCE CORP |
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| PAN AMERICAN LIFE INSURANCE GROUP (National Association of Insurance Commissioners NAIC id number: 12952 ) |
| Policy contract number | 88575 |
| Policy instance | 1 |
| Insurance contract or identification number | 88575 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $20,764 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | 1-15320 |
| Policy instance | 1 |
| Insurance contract or identification number | 1-15320 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $24,971 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
| Policy contract number | 1-15320 |
| Policy instance | 1 |
| Insurance contract or identification number | 1-15320 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2008-11-01 | | Insurance policy end date | 2009-10-31 | | Total amount of commissions paid to insurance broker | USD $20,866 | | Health Insurance Welfare Benefit | Yes | | 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 $20,866 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | THE LOYALTY INSURANCE SERVICES |
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