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WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 401k Plan overview

Plan NameWILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN
Plan identification number 501

WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

WILDFLOWER BREAD COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name:WILDFLOWER BREAD COMPANY, LLC
Employer identification number (EIN):800829894
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Additional information about WILDFLOWER BREAD COMPANY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5173757

More information about WILDFLOWER BREAD COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-06-01
5012019-06-01
5012018-06-01
5012017-06-01CHERYL CAMPBELL CHERYL CAMPBELL2018-12-19
5012017-05-01CHERYL CAMPBELL
5012016-05-01CHERYL CAMPBELL
5012015-05-01CHERYL CAMPBELL
5012014-05-01CHERYL CAMPBELL
5012013-05-01CHERYL CAMPBELL
5012012-05-01CHERYL CAMPBELL
5012011-05-01CHERYL CAMPBELL
5012010-05-01CHERYL CAMPBELL
5012009-05-01CHERYL CAMPBELL

Plan Statistics for WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN

401k plan membership statisitcs for WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN

Measure Date Value
2022: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-06-01147
Total number of active participants reported on line 7a of the Form 55002022-06-01149
Number of retired or separated participants receiving benefits2022-06-010
Number of other retired or separated participants entitled to future benefits2022-06-010
Total of all active and inactive participants2022-06-01149
2019: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01167
Total number of active participants reported on line 7a of the Form 55002019-06-0173
Number of retired or separated participants receiving benefits2019-06-014
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-0177
2018: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01194
Total number of active participants reported on line 7a of the Form 55002018-06-01165
Number of retired or separated participants receiving benefits2018-06-012
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01167
2017: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01175
Total number of active participants reported on line 7a of the Form 55002017-06-01193
Number of retired or separated participants receiving benefits2017-06-011
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01194
Total participants, beginning-of-year2017-05-01175
Total number of active participants reported on line 7a of the Form 55002017-05-01171
Number of retired or separated participants receiving benefits2017-05-014
Number of other retired or separated participants entitled to future benefits2017-05-010
Total of all active and inactive participants2017-05-01175
2016: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01158
Total number of active participants reported on line 7a of the Form 55002016-05-01171
Number of retired or separated participants receiving benefits2016-05-014
Number of other retired or separated participants entitled to future benefits2016-05-010
Total of all active and inactive participants2016-05-01175
2015: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01155
Total number of active participants reported on line 7a of the Form 55002015-05-01155
Number of retired or separated participants receiving benefits2015-05-013
Number of other retired or separated participants entitled to future benefits2015-05-010
Total of all active and inactive participants2015-05-01158
2014: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01175
Total number of active participants reported on line 7a of the Form 55002014-05-01187
Number of retired or separated participants receiving benefits2014-05-010
Number of other retired or separated participants entitled to future benefits2014-05-010
Total of all active and inactive participants2014-05-01187
2013: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01108
Total number of active participants reported on line 7a of the Form 55002013-05-01175
Number of retired or separated participants receiving benefits2013-05-010
Number of other retired or separated participants entitled to future benefits2013-05-010
Total of all active and inactive participants2013-05-01175
2012: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01108
Total number of active participants reported on line 7a of the Form 55002012-05-01108
Number of retired or separated participants receiving benefits2012-05-010
Number of other retired or separated participants entitled to future benefits2012-05-010
Total of all active and inactive participants2012-05-01108
Total participants2012-05-01108
2011: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01117
Total number of active participants reported on line 7a of the Form 55002011-05-01108
Number of retired or separated participants receiving benefits2011-05-010
Number of other retired or separated participants entitled to future benefits2011-05-010
Total of all active and inactive participants2011-05-01108
Total participants2011-05-01108
2010: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01101
Total number of active participants reported on line 7a of the Form 55002010-05-01117
Number of retired or separated participants receiving benefits2010-05-010
Number of other retired or separated participants entitled to future benefits2010-05-010
Total of all active and inactive participants2010-05-01117
Total participants2010-05-01117
2009: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-01100
Total number of active participants reported on line 7a of the Form 55002009-05-01101
Number of retired or separated participants receiving benefits2009-05-010
Number of other retired or separated participants entitled to future benefits2009-05-010
Total of all active and inactive participants2009-05-01101
Total participants2009-05-01101

Form 5500 Responses for WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN

2022: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-06-01Type of plan entitySingle employer plan
2022-06-01Submission has been amendedNo
2022-06-01This submission is the final filingNo
2022-06-01This return/report is a short plan year return/report (less than 12 months)No
2022-06-01Plan is a collectively bargained planNo
2022-06-01Plan funding arrangement – InsuranceYes
2022-06-01Plan funding arrangement – General assets of the sponsorYes
2022-06-01Plan benefit arrangement – InsuranceYes
2022-06-01Plan benefit arrangement – General assets of the sponsorYes
2019: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedNo
2019-06-01This submission is the final filingNo
2019-06-01This return/report is a short plan year return/report (less than 12 months)No
2019-06-01Plan is a collectively bargained planNo
2019-06-01Plan funding arrangement – General assets of the sponsorYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – General assets of the sponsorYes
2018: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – General assets of the sponsorYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – General assets of the sponsorYes
2017: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2017-05-01Type of plan entitySingle employer plan
2017-05-01Submission has been amendedNo
2017-05-01This submission is the final filingNo
2017-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-05-01Plan is a collectively bargained planNo
2017-05-01Plan funding arrangement – General assets of the sponsorYes
2017-05-01Plan benefit arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – General assets of the sponsorYes
2016: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)No
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes
2015: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Submission has been amendedNo
2015-05-01This submission is the final filingNo
2015-05-01This return/report is a short plan year return/report (less than 12 months)No
2015-05-01Plan is a collectively bargained planNo
2015-05-01Plan funding arrangement – General assets of the sponsorYes
2015-05-01Plan benefit arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – General assets of the sponsorYes
2014: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedNo
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)No
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – General assets of the sponsorYes
2014-05-01Plan benefit arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – General assets of the sponsorYes
2013: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – General assets of the sponsorYes
2013-05-01Plan benefit arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – General assets of the sponsorYes
2012: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – General assets of the sponsorYes
2012-05-01Plan benefit arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – General assets of the sponsorYes
2011: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Submission has been amendedNo
2011-05-01This submission is the final filingNo
2011-05-01This return/report is a short plan year return/report (less than 12 months)No
2011-05-01Plan is a collectively bargained planNo
2011-05-01Plan funding arrangement – General assets of the sponsorYes
2011-05-01Plan benefit arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – General assets of the sponsorYes
2010: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Submission has been amendedNo
2010-05-01This submission is the final filingNo
2010-05-01This return/report is a short plan year return/report (less than 12 months)No
2010-05-01Plan is a collectively bargained planNo
2010-05-01Plan funding arrangement – General assets of the sponsorYes
2010-05-01Plan benefit arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – General assets of the sponsorYes
2009: WILDFLOWER BREAD COMPANY WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01First time form 5500 has been submittedYes
2009-05-01Submission has been amendedNo
2009-05-01This submission is the final filingNo
2009-05-01This return/report is a short plan year return/report (less than 12 months)No
2009-05-01Plan is a collectively bargained planNo
2009-05-01Plan funding arrangement – General assets of the sponsorYes
2009-05-01Plan benefit arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911296
Policy instance 5
Insurance contract or identification number911296
Number of Individuals Covered280
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $4,299
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $42,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,215
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number31567
Policy instance 4
Insurance contract or identification number31567
Number of Individuals Covered154
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $22,008
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $145,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,008
Insurance broker organization code?3
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract number8351329
Policy instance 3
Insurance contract or identification number8351329
Number of Individuals Covered90
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $8,362
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $83,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,362
Insurance broker organization code?3
TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 )
Policy contract number652150
Policy instance 2
Insurance contract or identification number652150
Number of Individuals Covered181
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,360
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $31,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,360
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305066
Policy instance 1
Insurance contract or identification number305066
Number of Individuals Covered40
Insurance policy start date2022-06-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $2,094
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $13,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,094
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911296
Policy instance 5
Insurance contract or identification number911296
Number of Individuals Covered165
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,572
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $42,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,572
Insurance broker organization code?3
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract number8351329
Policy instance 4
Insurance contract or identification number8351329
Number of Individuals Covered9
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $10,226
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $91,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,226
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305066
Policy instance 3
Insurance contract or identification number305066
Number of Individuals Covered63
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $1,290
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $11,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,290
Insurance broker organization code?3
TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 )
Policy contract number652150
Policy instance 2
Insurance contract or identification number652150
Number of Individuals Covered17
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,001
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $33,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,001
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number31567
Policy instance 1
Insurance contract or identification number31567
Number of Individuals Covered57
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $28,777
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $135,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,777
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911296
Policy instance 5
Insurance contract or identification number911296
Number of Individuals Covered311
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $5,110
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $51,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,110
Insurance broker organization code?3
TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 )
Policy contract number652150
Policy instance 4
Insurance contract or identification number652150
Number of Individuals Covered195
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,985
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $27,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,985
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305066
Policy instance 3
Insurance contract or identification number305066
Number of Individuals Covered49
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,322
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $16,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,322
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number31567
Policy instance 2
Insurance contract or identification number31567
Number of Individuals Covered113
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $34,761
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $143,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,761
Insurance broker organization code?3
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract number8351329
Policy instance 1
Insurance contract or identification number8351329
Number of Individuals Covered102
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $10,119
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $102,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,119
Insurance broker organization code?3
AXIS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 37273 )
Policy contract number8351329
Policy instance 4
Insurance contract or identification number8351329
Number of Individuals Covered106
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $7,036
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $73,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,036
Insurance broker organization code?3
Insurance broker nameJP GRIFFIN COMPANIES LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305066
Policy instance 3
Insurance contract or identification number305066
Number of Individuals Covered73
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,998
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $17,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,998
Insurance broker organization code?3
Insurance broker nameJP GRIFFIN COMPANIES, LLC
TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 )
Policy contract number652150
Policy instance 2
Insurance contract or identification number652150
Number of Individuals Covered145
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,128
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,128
Insurance broker organization code?3
Insurance broker nameJP GRIFFIN COMPANIES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911296
Policy instance 1
Insurance contract or identification number911296
Number of Individuals Covered265
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $4,785
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $52,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,785
Insurance broker organization code?3
Insurance broker nameJP GRIFFIN COMPANIES LLC

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