QUILEUTE TRIBAL COUNCIL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN
401k plan membership statisitcs for QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2021: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 127 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 1 |
| 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 | 128 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 137 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 1 |
| 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 | 138 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 148 |
| 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 | 148 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 148 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 148 |
| Number of employers contributing to the scheme | 2018-12-01 | 0 |
| 2017: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 124 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 124 |
| Number of employers contributing to the scheme | 2017-12-01 | 0 |
| 2016: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 123 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 123 |
| Number of employers contributing to the scheme | 2016-12-01 | 0 |
| 2015: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 136 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 136 |
| 2014: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 125 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 125 |
| 2013: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 122 |
| Number of retired or separated participants receiving benefits | 2013-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-01 | 0 |
| Total of all active and inactive participants | 2013-12-01 | 123 |
| 2012: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 115 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 119 |
| 2011: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 117 |
| Number of retired or separated participants receiving benefits | 2011-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-01 | 0 |
| Total of all active and inactive participants | 2011-12-01 | 119 |
| 2010: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 107 |
| Number of retired or separated participants receiving benefits | 2010-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-01 | 0 |
| Total of all active and inactive participants | 2010-12-01 | 111 |
| 2009: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 110 |
| Number of retired or separated participants receiving benefits | 2009-12-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-01 | 0 |
| Total of all active and inactive participants | 2009-12-01 | 115 |
| 2021: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Submission has been amended | No |
| 2013-12-01 | This submission is the final filing | No |
| 2013-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-01 | Plan is a collectively bargained plan | No |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: QUILEUTE TRIBAL COUNCIL WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
| Policy contract number | 4022442 |
| Policy instance | 4 |
| Insurance contract or identification number | 4022442 | | Number of Individuals Covered | 267 | | 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 $8,892 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,534,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 8892 | | Additional information about fees paid to insurance broker | PREFERRED PRODUCER PROGRAM | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 7114043 |
| Policy instance | 3 |
| Insurance contract or identification number | 7114043 | | Number of Individuals Covered | 129 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| 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 | 140 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | 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 $4,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 889175G |
| Policy instance | 1 |
| Insurance contract or identification number | 889175G | | Number of Individuals Covered | 122 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $2,506 | | Total amount of fees paid to insurance company | USD $978 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $53,332 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,506 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 889175G |
| Policy instance | 1 |
| Insurance contract or identification number | 889175G | | Number of Individuals Covered | 135 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $2,646 | | Total amount of fees paid to insurance company | USD $1,515 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $57,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,646 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| 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 | 143 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | 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 $4,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941272 |
| Policy instance | 3 |
| Insurance contract or identification number | 941272 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $14,148 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $141,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,148 | | 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 | 7114043 |
| Policy instance | 4 |
| Insurance contract or identification number | 7114043 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $817 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,667 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $817 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
| Policy contract number | 10016096 |
| Policy instance | 5 |
| Insurance contract or identification number | 10016096 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,580,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
| Policy contract number | 10016096 |
| Policy instance | 5 |
| Insurance contract or identification number | 10016096 | | Number of Individuals Covered | 318 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $7,307 | | Total amount of fees paid to insurance company | USD $2,780 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,352,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,307 | | Amount paid for insurance broker fees | 2780 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 7114043 |
| Policy instance | 4 |
| Insurance contract or identification number | 7114043 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,125 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,693 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,125 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | D480 |
| Policy instance | 3 |
| Insurance contract or identification number | D480 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| 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 | 144 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | 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 $4,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 889175G |
| Policy instance | 1 |
| Insurance contract or identification number | 889175G | | Number of Individuals Covered | 138 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,666 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $33,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1666 | | Additional information about fees paid to insurance broker | BONUS | | 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 | 148 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-09-30 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50013410 |
| Policy instance | 1 |
| Insurance contract or identification number | 50013410 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,841 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $18,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,008 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | D480 |
| Policy instance | 3 |
| Insurance contract or identification number | D480 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $17,055 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $170,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,560 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50013410 |
| Policy instance | 4 |
| Insurance contract or identification number | 50013410 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,670 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,728 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
| Policy contract number | 10016096 |
| Policy instance | 6 |
| Insurance contract or identification number | 10016096 | | Number of Individuals Covered | 327 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $7,307 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,120,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,307 | | 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 | 07114043 |
| Policy instance | 5 |
| Insurance contract or identification number | 07114043 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $957 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $895 | | 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 | 6 |
| Insurance contract or identification number | EAP | | Number of Individuals Covered | 124 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | 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 $3,986 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50013410 |
| Policy instance | 5 |
| Insurance contract or identification number | 50013410 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $5,382 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,145 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50013410 |
| Policy instance | 4 |
| Insurance contract or identification number | 50013410 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $3,695 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $24,335 | | 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 | 7114043 |
| Policy instance | 3 |
| Insurance contract or identification number | 7114043 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $375 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,690 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
| Policy contract number | 10016096 |
| Policy instance | 1 |
| Insurance contract or identification number | 10016096 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $30,074 | | Total amount of fees paid to insurance company | USD $199 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | D480 |
| Policy instance | 2 |
| Insurance contract or identification number | D480 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $14,387 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $171,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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