YAKIMA VALLEY COUNCIL ON ALCOHOL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN
401k plan membership statisitcs for TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 90 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 90 |
| Number of employers contributing to the scheme | 2022-10-01 | 0 |
| 2021: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 101 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 150 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 150 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 65 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 101 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 101 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 65 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 65 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 94 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 94 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 0 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 0 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: TRIUMPH TREATMENT SERVICES WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 102 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 102 |
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 5 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $898 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $6,230 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $661 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 4 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $3,194 | | Total amount of fees paid to insurance company | USD $78 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $13,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,428 | | Amount paid for insurance broker fees | 30 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 010931 |
| Policy instance | 3 |
| Insurance contract or identification number | 010931 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $5,410 | | Total amount of fees paid to insurance company | USD $1,803 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $36,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,410 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 2 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $753 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $753 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 150 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $180 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $3,600 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $180 | | Insurance broker organization code? | 3 |
|
| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 1 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 150 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 2 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,283 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,251 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $758 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 010931 |
| Policy instance | 3 |
| Insurance contract or identification number | 010931 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $5,054 | | Total amount of fees paid to insurance company | USD $2,158 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $33,693 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,054 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 4 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,948 | | Total amount of fees paid to insurance company | USD $24 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,267 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $844 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 5 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,068 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $10,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $594 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1032722 |
| Policy instance | 1 |
| Insurance contract or identification number | 1032722 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $30,976 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $570,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,976 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 167 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $200 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $200 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 3 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $679 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $679 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9485 |
| Policy instance | 4 |
| Insurance contract or identification number | 9485 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,654 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,654 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 5 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,346 | | Total amount of fees paid to insurance company | USD $120 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $9,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $697 | | Amount paid for insurance broker fees | 68 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 6 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,604 | | Total amount of fees paid to insurance company | USD $7 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $489 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B7TF |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG0B7TF | | Number of Individuals Covered | 101 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,158 | | Total amount of fees paid to insurance company | USD $600 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,158 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B7TF |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG0B7TF | | Number of Individuals Covered | 115 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,588 | | Total amount of fees paid to insurance company | USD $730 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,588 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 6 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $4,457 | | Total amount of fees paid to insurance company | USD $167 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $23,873 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,537 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 5 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $2,872 | | Total amount of fees paid to insurance company | USD $143 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,524 | | Amount paid for insurance broker fees | 82 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9485 |
| Policy instance | 4 |
| Insurance contract or identification number | 9485 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $4,248 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,248 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 3 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $820 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $525 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 167 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $200 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $200 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1032722 |
| Policy instance | 1 |
| Insurance contract or identification number | 1032722 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $37,643 | | Total amount of fees paid to insurance company | USD $632 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $663,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,643 | | Amount paid for insurance broker fees | 632 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM. | | Insurance broker organization code? | 3 |
|
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1032722 |
| Policy instance | 1 |
| Insurance contract or identification number | 1032722 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $40,857 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $780,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,857 | | Insurance broker organization code? | 3 |
|
| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 167 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $200 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $200 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 3 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $837 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $837 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 9485 |
| Policy instance | 4 |
| Insurance contract or identification number | 9485 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,466 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,466 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN FAMILY LIFE INSURANCE COMPANY OF COLUMBUS (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 5 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,957 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $6,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $960 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 6 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $5,731 | | Total amount of fees paid to insurance company | USD $487 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $32,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,433 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B7TF |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG0B7TF | | Number of Individuals Covered | 142 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $1,697 | | Total amount of fees paid to insurance company | USD $823 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $11,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,315 | | Amount paid for insurance broker fees | 643 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
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| FIRST CHOICE HEALTH EAP (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | EAP |
| Policy instance | 2 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 179 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $203 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30010221 |
| Policy instance | 3 |
| Insurance contract or identification number | 30010221 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $803 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 09485 |
| Policy instance | 4 |
| Insurance contract or identification number | 09485 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $3,773 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 78756 |
| Policy instance | 5 |
| Insurance contract or identification number | 78756 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $316 | | Total amount of fees paid to insurance company | USD $15 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $3,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3419900 |
| Policy instance | 6 |
| Insurance contract or identification number | E3419900 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $6,960 | | Total amount of fees paid to insurance company | USD $545 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $27,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B7TF |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG0B7TF | | Number of Individuals Covered | 137 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,804 | | Total amount of fees paid to insurance company | USD $643 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,029 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 1032722 |
| Policy instance | 1 |
| Insurance contract or identification number | 1032722 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $41,171 | | Total amount of fees paid to insurance company | USD $2,314 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $749,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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