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PROVATION HEALTH AND WELFARE PLAN 401k Plan overview

Plan NamePROVATION HEALTH AND WELFARE PLAN
Plan identification number 501

PROVATION HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Prepaid legal
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

PROVATION SOFTWARE GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name:PROVATION SOFTWARE GROUP, INC.
Employer identification number (EIN):814122667
NAIC Classification:541511
NAIC Description:Custom Computer Programming Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PROVATION HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01TOM MONTELEONE2023-10-16
5012021-01-01TOM MONTELEONE2023-02-06
5012020-01-01SUSAN M. HANSON2021-08-04
5012019-03-01SUSAN M. HANSON2020-09-22
5012018-03-01SUSAN M. HANSON2019-12-13

Plan Statistics for PROVATION HEALTH AND WELFARE PLAN

401k plan membership statisitcs for PROVATION HEALTH AND WELFARE PLAN

Measure Date Value
2022: PROVATION HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01277
Total number of active participants reported on line 7a of the Form 55002022-01-01296
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01296
Number of employers contributing to the scheme2022-01-010
2021: PROVATION HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01210
Total number of active participants reported on line 7a of the Form 55002021-01-01277
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01277
Number of employers contributing to the scheme2021-01-010
2020: PROVATION HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01198
Total number of active participants reported on line 7a of the Form 55002020-01-01210
Number of retired or separated participants receiving benefits2020-01-015
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01215
Number of employers contributing to the scheme2020-01-010
2019: PROVATION HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01148
Total number of active participants reported on line 7a of the Form 55002019-03-01192
Number of retired or separated participants receiving benefits2019-03-016
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01198
Number of employers contributing to the scheme2019-03-010
2018: PROVATION HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01154
Total number of active participants reported on line 7a of the Form 55002018-03-01148
Number of retired or separated participants receiving benefits2018-03-010
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01148
Number of employers contributing to the scheme2018-03-010

Form 5500 Responses for PROVATION HEALTH AND WELFARE PLAN

2022: PROVATION HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: PROVATION HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedYes
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: PROVATION HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: PROVATION HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – InsuranceYes
2018: PROVATION HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01First time form 5500 has been submittedYes
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJ7K
Policy instance 6
Insurance contract or identification numberGLUG0BJ7K
Number of Individuals Covered296
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $29,784
Total amount of fees paid to insurance companyUSD $12,161
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $198,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,784
Amount paid for insurance broker fees8234
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number71896-3
Policy instance 5
Insurance contract or identification number71896-3
Number of Individuals Covered505
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,350
Total amount of fees paid to insurance companyUSD $920
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $43,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,350
Amount paid for insurance broker fees920
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number9908-3661
Policy instance 4
Insurance contract or identification number9908-3661
Number of Individuals Covered296
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $400
Total amount of fees paid to insurance companyUSD $45
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $400
Amount paid for insurance broker fees45
Additional information about fees paid to insurance brokerCONTINGENT COMMISSION
Insurance broker organization code?3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 3
Insurance contract or identification number9901859
Number of Individuals Covered296
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $1,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10165141001
Policy instance 2
Insurance contract or identification number10165141001
Number of Individuals Covered400
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,884
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $37,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $987
Amount paid for insurance broker fees0
Insurance broker organization code?3
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number255214
Policy instance 1
Insurance contract or identification number255214
Number of Individuals Covered562
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $208,729
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,802,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $208,729
Amount paid for insurance broker fees0
Insurance broker organization code?3
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number255214
Policy instance 1
Insurance contract or identification number255214
Number of Individuals Covered320
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $155,139
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,169,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $155,139
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10165141001
Policy instance 2
Insurance contract or identification number10165141001
Number of Individuals Covered391
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $492
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $492
Amount paid for insurance broker fees0
Insurance broker organization code?3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 3
Insurance contract or identification number9901859
Number of Individuals Covered27
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $601
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $6,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $601
Amount paid for insurance broker fees0
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number9908-3661
Policy instance 4
Insurance contract or identification number9908-3661
Number of Individuals Covered277
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $400
Total amount of fees paid to insurance companyUSD $83
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $400
Amount paid for insurance broker fees83
Additional information about fees paid to insurance brokerCONTINGENT COMMISSION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number214885
Policy instance 5
Insurance contract or identification number214885
Number of Individuals Covered277
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Welfare Benefit Premiums Paid to CarrierUSD $-296
Commission paid to Insurance BrokerUSD $1,112
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJ7K
Policy instance 6
Insurance contract or identification numberGLUG0BJ7K
Number of Individuals Covered277
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $38,263
Total amount of fees paid to insurance companyUSD $8,502
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $255,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,263
Amount paid for insurance broker fees4575
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJ7K
Policy instance 8
Insurance contract or identification numberGLUG0BJ7K
Number of Individuals Covered209
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $16,871
Total amount of fees paid to insurance companyUSD $9,707
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $112,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,871
Amount paid for insurance broker fees5927
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 7
Insurance contract or identification number9901859
Number of Individuals Covered20
Insurance policy start date2020-03-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $372
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $2,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $372
Amount paid for insurance broker fees0
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number9908-3661
Policy instance 6
Insurance contract or identification number9908-3661
Number of Individuals Covered210
Insurance policy start date2020-03-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $356
Total amount of fees paid to insurance companyUSD $60
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $1,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $356
Amount paid for insurance broker fees60
Additional information about fees paid to insurance brokerCONTINGENT COMMISSION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number214885
Policy instance 5
Insurance contract or identification number214885
Number of Individuals Covered66
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,799
Total amount of fees paid to insurance companyUSD $321
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $14,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,239
Amount paid for insurance broker fees52
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number9908-3661
Policy instance 4
Insurance contract or identification number9908-3661
Number of Individuals Covered210
Insurance policy start date2020-01-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 3
Insurance contract or identification number9901859
Number of Individuals Covered17
Insurance policy start date2019-03-01
Insurance policy end date2020-02-28
Total amount of commissions paid to insurance brokerUSD $398
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $7,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $398
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10165141001
Policy instance 2
Insurance contract or identification number10165141001
Number of Individuals Covered253
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $762
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $762
Amount paid for insurance broker fees0
Insurance broker organization code?3
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number255214
Policy instance 1
Insurance contract or identification number255214
Number of Individuals Covered222
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $117,399
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,357,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $117,399
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10165141001
Policy instance 2
Insurance contract or identification number10165141001
Number of Individuals Covered228
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $410
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,014
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $410
Amount paid for insurance broker fees0
Insurance broker organization code?3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 3
Insurance contract or identification number9901859
Number of Individuals Covered17
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $332
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $7,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $332
Amount paid for insurance broker fees0
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number9908-3661
Policy instance 4
Insurance contract or identification number9908-3661
Number of Individuals Covered192
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $425
Total amount of fees paid to insurance companyUSD $63
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $425
Amount paid for insurance broker fees63
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number214885
Policy instance 5
Insurance contract or identification number214885
Number of Individuals Covered40
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,745
Total amount of fees paid to insurance companyUSD $630
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $7,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,196
Amount paid for insurance broker fees73
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJ7K
Policy instance 6
Insurance contract or identification numberGLUG0BJ7K
Number of Individuals Covered200
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $18,764
Total amount of fees paid to insurance companyUSD $3,150
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $125,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,764
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATION
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number255214
Policy instance 1
Insurance contract or identification number255214
Number of Individuals Covered363
Insurance policy start date2019-03-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $81,103
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,600,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,103
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5951358
Policy instance 2
Insurance contract or identification number5951358
Number of Individuals Covered344
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $173,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract number255214
Policy instance 1
Insurance contract or identification number255214
Number of Individuals Covered378
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $97,418
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,948,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $97,418
Amount paid for insurance broker fees0
Insurance broker organization code?3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number9901859
Policy instance 4
Insurance contract or identification number9901859
Number of Individuals Covered38
Insurance policy start date2018-08-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $296
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $296
Amount paid for insurance broker fees0
Insurance broker organization code?3
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number99083661
Policy instance 5
Insurance contract or identification number99083661
Number of Individuals Covered180
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $352
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $1,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $352
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0214884
Policy instance 6
Insurance contract or identification number0214884
Number of Individuals Covered65
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $825
Total amount of fees paid to insurance companyUSD $508
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $4,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $660
Amount paid for insurance broker fees95
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0214885
Policy instance 7
Insurance contract or identification number0214885
Number of Individuals Covered71
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $3,536
Total amount of fees paid to insurance companyUSD $1,680
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $19,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,829
Amount paid for insurance broker fees95
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 8
Insurance contract or identification number00
Number of Individuals Covered40
Insurance policy start date2018-03-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $386
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $3,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $386
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number1016514
Policy instance 3
Insurance contract or identification number1016514
Number of Individuals Covered214
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $627
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,710
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $627
Amount paid for insurance broker fees0
Insurance broker organization code?3

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