401k Plan data: OIC OF WA WELFARE BENEFIT PLAN plan

OIC OF WA WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	OIC OF WA WELFARE BENEFIT PLAN
Plan identification number	501

OIC OF WA WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

OIC OF WASHINGTON has sponsored the creation of one or more 401k plans.

Company Name: OIC OF WASHINGTON

Employer identification number (EIN): 910873024

NAIC Classification: 611000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OIC OF WA WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 DEREJE ALEMENEH MEKURIA 2023-07-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	DEREJE ALEMENEH MEKURIA	2023-07-07

Plan Statistics for OIC OF WA WELFARE BENEFIT PLAN

401k plan membership statisitcs for OIC OF WA WELFARE BENEFIT PLAN

Measure Date Value
2022: OIC OF WA WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 102
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 102
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 102
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: OIC OF WA WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	102
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	102
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	102
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for OIC OF WA WELFARE BENEFIT PLAN

2022: OIC OF WA WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )

Policy contract number

10013742

Policy instance

Insurance contract or identification number	10013742
Number of Individuals Covered	139
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $52,667
Total amount of fees paid to insurance company	USD $1,300
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $979,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $52,667
Amount paid for insurance broker fees	1300
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )

Policy contract number

8309

Policy instance

Insurance contract or identification number	8309
Number of Individuals Covered	154
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,580
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $71,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,580
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

30024187

Policy instance

Insurance contract or identification number	30024187
Number of Individuals Covered	84
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $802
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $802
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WA07358W

Policy instance

Insurance contract or identification number	WA07358W
Number of Individuals Covered	102
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,320
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $83,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,320
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )

Policy contract number

OICEAP

Policy instance

Insurance contract or identification number	OICEAP
Number of Individuals Covered	118
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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 $3,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	OIC OF WASHINGTON
Employer identification number (EIN):	910873024
NAIC Classification:	611000