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UCBT RETIREE HEALTH PLAN 401k Plan overview

Plan NameUCBT RETIREE HEALTH PLAN
Plan identification number 501

UCBT RETIREE HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision

401k Sponsoring company profile

UCBT RETIREE HEALTH PLAN has sponsored the creation of one or more 401k plans.

Company Name:UCBT RETIREE HEALTH PLAN
Employer identification number (EIN):822616834
NAIC Classification:445110
NAIC Description:Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UCBT RETIREE HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01JACQUES S LOVEALL2023-10-06 KEVIN SEARS2023-10-02
5012021-01-01JACQUES S. LOVEALL2022-10-14 KEVIN SEARS2022-10-13
5012020-01-01JACQUES S LOVEALL2021-09-22 KEVIN SEARS2021-09-27
5012020-01-01JACQUES S LOVEALL2021-09-22 KEVIN SEARS2021-09-27
5012019-01-01JACQUES S LOVEALL2020-10-01 KEVIN SEARS2020-10-01
5012019-01-01JACQUES S LOVEALL2020-10-01 KEVIN SEARS2020-10-01
5012018-01-01JACQUES LOVEALL2019-10-10 KEVIN SEARS2019-10-10

Plan Statistics for UCBT RETIREE HEALTH PLAN

401k plan membership statisitcs for UCBT RETIREE HEALTH PLAN

Measure Date Value
2022: UCBT RETIREE HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01104
Number of retired or separated participants receiving benefits2022-01-01221
Total of all active and inactive participants2022-01-01221
Number of employers contributing to the scheme2022-01-012
2021: UCBT RETIREE HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-0186
Number of retired or separated participants receiving benefits2021-01-01104
Total of all active and inactive participants2021-01-01104
Number of employers contributing to the scheme2021-01-012
2020: UCBT RETIREE HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-0159
Number of retired or separated participants receiving benefits2020-01-0186
Total of all active and inactive participants2020-01-0186
Number of employers contributing to the scheme2020-01-012
2019: UCBT RETIREE HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-0129
Number of retired or separated participants receiving benefits2019-01-0159
Total of all active and inactive participants2019-01-0159
Number of employers contributing to the scheme2019-01-012
2018: UCBT RETIREE HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-010
Number of retired or separated participants receiving benefits2018-01-0129
Total of all active and inactive participants2018-01-0129

Financial Data on UCBT RETIREE HEALTH PLAN

Measure Date Value
2022 : UCBT RETIREE HEALTH PLAN 2022 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$101,226
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2022-12-31$79,315
Total income from all sources (including contributions)2022-12-31$1,668,777
Total of all expenses incurred2022-12-31$1,351,222
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2022-12-31$1,206,735
Total contributions o plan (from employers,participants, others, non cash contrinutions)2022-12-31$1,666,852
Value of total assets at end of year2022-12-31$1,748,396
Value of total assets at beginning of year2022-12-31$1,408,930
Total of administrative expenses incurred including professional, contract, advisory and management fees2022-12-31$144,487
Total interest from all sources2022-12-31$1,925
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-12-31No
Administrative expenses professional fees incurred2022-12-31$60,346
Was this plan covered by a fidelity bond2022-12-31Yes
Value of fidelity bond cover2022-12-31$1,000,000
If this is an individual account plan, was there a blackout period2022-12-31No
Were there any nonexempt tranactions with any party-in-interest2022-12-31No
Contributions received from participants2022-12-31$325,464
Income. Received or receivable in cash from other sources (including rollovers)2022-12-31$24,133
Value of other receiveables (less allowance for doubtful accounts) at end of year2022-12-31$380,770
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2022-12-31$436,675
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2022-12-31$10,144
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2022-12-31$1,696
Administrative expenses (other) incurred2022-12-31$11,841
Liabilities. Value of operating payables at end of year2022-12-31$12,587
Liabilities. Value of operating payables at beginning of year2022-12-31$23,994
Total non interest bearing cash at end of year2022-12-31$1,367,626
Total non interest bearing cash at beginning of year2022-12-31$972,255
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Value of net income/loss2022-12-31$317,555
Value of net assets at end of year (total assets less liabilities)2022-12-31$1,647,170
Value of net assets at beginning of year (total assets less liabilities)2022-12-31$1,329,615
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2022-12-31No
Were any leases to which the plan was party in default or uncollectible2022-12-31No
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2022-12-31$1,925
Expenses. Payments to insurance carriers foe the provision of benefits2022-12-31$161,130
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-12-31No
Was there a failure to transmit to the plan any participant contributions2022-12-31No
Has the plan failed to provide any benefit when due under the plan2022-12-31No
Contributions received in cash from employer2022-12-31$1,317,255
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2022-12-31$1,045,605
Contract administrator fees2022-12-31$72,300
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32022-12-31No
Liabilities. Value of benefit claims payable at end of year2022-12-31$78,495
Liabilities. Value of benefit claims payable at beginning of year2022-12-31$53,625
Did the plan have assets held for investment2022-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-12-31No
Opinion of an independent qualified public accountant for this plan2022-12-31Unqualified
Accountancy firm name2022-12-31EIDE BAILLY, LLP
Accountancy firm EIN2022-12-31450250958
2021 : UCBT RETIREE HEALTH PLAN 2021 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$79,315
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$209,727
Total income from all sources (including contributions)2021-12-31$1,548,157
Total of all expenses incurred2021-12-31$1,222,065
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$1,067,223
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$1,547,282
Value of total assets at end of year2021-12-31$1,390,378
Value of total assets at beginning of year2021-12-31$1,194,698
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$154,842
Total interest from all sources2021-12-31$875
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Administrative expenses professional fees incurred2021-12-31$72,796
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$1,000,000
If this is an individual account plan, was there a blackout period2021-12-31No
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$259,954
Income. Received or receivable in cash from other sources (including rollovers)2021-12-31$18,466
Value of other receiveables (less allowance for doubtful accounts) at end of year2021-12-31$418,123
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2021-12-31$353,441
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2021-12-31$1,696
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2021-12-31$98,483
Administrative expenses (other) incurred2021-12-31$11,490
Liabilities. Value of operating payables at end of year2021-12-31$23,994
Liabilities. Value of operating payables at beginning of year2021-12-31$10,822
Total non interest bearing cash at end of year2021-12-31$972,255
Total non interest bearing cash at beginning of year2021-12-31$841,257
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$326,092
Value of net assets at end of year (total assets less liabilities)2021-12-31$1,311,063
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$984,971
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2021-12-31$875
Expenses. Payments to insurance carriers foe the provision of benefits2021-12-31$145,706
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31No
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$1,268,862
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$921,517
Contract administrator fees2021-12-31$70,556
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32021-12-31No
Liabilities. Value of benefit claims payable at end of year2021-12-31$53,625
Liabilities. Value of benefit claims payable at beginning of year2021-12-31$100,422
Did the plan have assets held for investment2021-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31EIDE BAILLY, LLP
Accountancy firm EIN2021-12-31450250958
2020 : UCBT RETIREE HEALTH PLAN 2020 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$209,727
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$109,334
Total income from all sources (including contributions)2020-12-31$1,286,731
Total of all expenses incurred2020-12-31$1,039,277
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$885,336
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$1,284,673
Value of total assets at end of year2020-12-31$1,194,698
Value of total assets at beginning of year2020-12-31$846,851
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$153,941
Total interest from all sources2020-12-31$2,058
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Administrative expenses professional fees incurred2020-12-31$51,925
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$224,203
Value of other receiveables (less allowance for doubtful accounts) at end of year2020-12-31$353,441
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2020-12-31$509,677
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2020-12-31$176,120
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2020-12-31$100,000
Administrative expenses (other) incurred2020-12-31$12,862
Liabilities. Value of operating payables at end of year2020-12-31$10,822
Liabilities. Value of operating payables at beginning of year2020-12-31$44
Total non interest bearing cash at end of year2020-12-31$841,257
Total non interest bearing cash at beginning of year2020-12-31$337,174
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$247,454
Value of net assets at end of year (total assets less liabilities)2020-12-31$984,971
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$737,517
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Interest earned on other investments2020-12-31$2,058
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$155,417
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31No
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$1,060,470
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$729,919
Contract administrator fees2020-12-31$89,154
Liabilities. Value of benefit claims payable at end of year2020-12-31$22,785
Liabilities. Value of benefit claims payable at beginning of year2020-12-31$9,290
Did the plan have assets held for investment2020-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31EIDE BAILLY LLP
Accountancy firm EIN2020-12-31450250958
2019 : UCBT RETIREE HEALTH PLAN 2019 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$109,334
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$23,859
Total income from all sources (including contributions)2019-12-31$1,663,899
Total of all expenses incurred2019-12-31$1,076,034
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$978,110
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$1,660,996
Value of total assets at end of year2019-12-31$846,851
Value of total assets at beginning of year2019-12-31$173,511
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$97,924
Total interest from all sources2019-12-31$2,903
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Administrative expenses professional fees incurred2019-12-31$32,847
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$1,000,000
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$82,669
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$509,677
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$162,175
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2019-12-31$100,000
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2019-12-31$20,000
Administrative expenses (other) incurred2019-12-31$6,092
Liabilities. Value of operating payables at end of year2019-12-31$44
Total non interest bearing cash at end of year2019-12-31$337,174
Total non interest bearing cash at beginning of year2019-12-31$11,336
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$587,865
Value of net assets at end of year (total assets less liabilities)2019-12-31$737,517
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$149,652
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Interest earned on other investments2019-12-31$2,903
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$89,853
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$1,578,327
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2019-12-31$888,257
Contract administrator fees2019-12-31$58,985
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-12-31No
Liabilities. Value of benefit claims payable at end of year2019-12-31$9,290
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$3,859
Did the plan have assets held for investment2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31EIDE BAILLY LLP
Accountancy firm EIN2019-12-31450250958
2018 : UCBT RETIREE HEALTH PLAN 2018 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$23,859
Total income from all sources (including contributions)2018-12-31$532,217
Total of all expenses incurred2018-12-31$382,565
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$329,891
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$532,217
Value of total assets at end of year2018-12-31$173,511
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$52,674
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Administrative expenses professional fees incurred2018-12-31$6,972
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$1,000,000
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Contributions received from participants2018-12-31$62,116
Value of other receiveables (less allowance for doubtful accounts) at end of year2018-12-31$162,175
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2018-12-31$20,000
Administrative expenses (other) incurred2018-12-31$3,748
Total non interest bearing cash at end of year2018-12-31$11,336
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$149,652
Value of net assets at end of year (total assets less liabilities)2018-12-31$149,652
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2018-12-31$66,368
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contributions received in cash from employer2018-12-31$470,101
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2018-12-31$263,523
Contract administrator fees2018-12-31$41,954
Liabilities. Value of benefit claims payable at end of year2018-12-31$3,859
Did the plan have assets held for investment2018-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31No
Opinion of an independent qualified public accountant for this plan2018-12-31Unqualified
Accountancy firm name2018-12-31EIDE BAILLY LLP
Accountancy firm EIN2018-12-31450250958

Form 5500 Responses for UCBT RETIREE HEALTH PLAN

2022: UCBT RETIREE HEALTH PLAN 2022 form 5500 responses
2022-01-01Type of plan entityMulti-employer plan
2022-01-01Plan is a collectively bargained planYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2021: UCBT RETIREE HEALTH PLAN 2021 form 5500 responses
2021-01-01Type of plan entityMulti-employer plan
2021-01-01Submission has been amendedYes
2021-01-01Plan is a collectively bargained planYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: UCBT RETIREE HEALTH PLAN 2020 form 5500 responses
2020-01-01Type of plan entityMulti-employer plan
2020-01-01Submission has been amendedYes
2020-01-01Plan is a collectively bargained planYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: UCBT RETIREE HEALTH PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01Plan is a collectively bargained planYes
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes
2018: UCBT RETIREE HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01First time form 5500 has been submittedYes
2018-01-01Plan is a collectively bargained planYes
2018-01-01Plan funding arrangement – TrustYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 )
Policy contract number47-MSL-000347-0
Policy instance 2
Insurance contract or identification number47-MSL-000347-0
Number of Individuals Covered38
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
Welfare Benefit Premiums Paid to CarrierUSD $34,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605686
Policy instance 1
Insurance contract or identification number605686
Number of Individuals Covered25
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
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $117,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 )
Policy contract number47-MSL-000347-0
Policy instance 2
Insurance contract or identification number47-MSL-000347-0
Number of Individuals Covered34
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,387
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $27,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,387
Additional information about fees paid to insurance brokerCOMMISSIONS PAID
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605686
Policy instance 1
Insurance contract or identification number605686
Number of Individuals Covered27
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
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $99,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 )
Policy contract number47-MSL-000347-0
Policy instance 3
Insurance contract or identification number47-MSL-000347-0
Number of Individuals Covered27
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $899
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $22,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $899
Additional information about fees paid to insurance brokerCOMMISSIONS PAID
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0065194
Policy instance 2
Insurance contract or identification numberW0065194
Number of Individuals Covered36
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605686
Policy instance 1
Insurance contract or identification number605686
Number of Individuals Covered26
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $120,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0065194
Policy instance 2
Insurance contract or identification numberW0065194
Number of Individuals Covered16
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605686
Policy instance 1
Insurance contract or identification number605686
Number of Individuals Covered19
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $82,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61557 )
Policy contract numberW0065194
Policy instance 2
Insurance contract or identification numberW0065194
Number of Individuals Covered12
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605686
Policy instance 1
Insurance contract or identification number605686
Number of Individuals Covered11
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $53,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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