401k Plan data: PHYSICIANS INSURANCE HEALTH & WELFARE PLAN plan

PHYSICIANS INSURANCE HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	PHYSICIANS INSURANCE HEALTH & WELFARE PLAN
Plan identification number	501

PHYSICIANS INSURANCE HEALTH & WELFARE PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

PHYSICIANS INSURANCE A MUTUAL COMPANY has sponsored the creation of one or more 401k plans.

Company Name: PHYSICIANS INSURANCE A MUTUAL COMPANY

Employer identification number (EIN): 911160717

NAIC Classification: 524150

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PHYSICIANS INSURANCE HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-03-01 ALISON TALBOT 2022-09-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-03-01	ALISON TALBOT	2022-09-30

Plan Statistics for PHYSICIANS INSURANCE HEALTH & WELFARE PLAN

401k plan membership statisitcs for PHYSICIANS INSURANCE HEALTH & WELFARE PLAN

Measure Date Value
2021: PHYSICIANS INSURANCE HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-03-01 102
Total number of active participants reported on line 7a of the Form 5500 2021-03-01 90
Number of retired or separated participants receiving benefits 2021-03-01 3
Number of other retired or separated participants entitled to future benefits 2021-03-01 0
Total of all active and inactive participants 2021-03-01 93
Number of employers contributing to the scheme 2021-03-01 0

Measure	Date	Value
2021: PHYSICIANS INSURANCE HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-03-01	102
Total number of active participants reported on line 7a of the Form 5500	2021-03-01	90
Number of retired or separated participants receiving benefits	2021-03-01	3
Number of other retired or separated participants entitled to future benefits	2021-03-01	0
Total of all active and inactive participants	2021-03-01	93
Number of employers contributing to the scheme	2021-03-01	0

Form 5500 Responses for PHYSICIANS INSURANCE HEALTH & WELFARE PLAN

2021: PHYSICIANS INSURANCE HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-03-01	Type of plan entity	Single employer plan
2021-03-01	Plan funding arrangement – Insurance	Yes
2021-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-03-01	Plan benefit arrangement – Insurance	Yes
2021-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

2195500

Policy instance

Insurance contract or identification number	2195500
Number of Individuals Covered	2
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $535
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $535
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

4017777

Policy instance

Insurance contract or identification number	4017777
Number of Individuals Covered	175
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $4,876
Total amount of fees paid to insurance company	USD $2,619
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,876
Amount paid for insurance broker fees	2619
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

12211996

Policy instance

Insurance contract or identification number	12211996
Number of Individuals Covered	92
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $854
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $854
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

887422G

Policy instance

Insurance contract or identification number	887422G
Number of Individuals Covered	91
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $7,226
Total amount of fees paid to insurance company	USD $7,951
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 $91,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,226
Amount paid for insurance broker fees	1572
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

99066745

Policy instance

Insurance contract or identification number	99066745
Number of Individuals Covered	90
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
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?	Yes

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8864100

Policy instance

Insurance contract or identification number	8864100
Number of Individuals Covered	160
Insurance policy start date	2021-03-01
Insurance policy end date	2022-02-28
Total amount of commissions paid to insurance broker	USD $50,092
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,122,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,092
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

Potentially related plans

PHYSICIANS INSURANCE COMPANY 401(K) PROFIT SHARING PLAN & TRUST [EIN = 134235490]

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Company Name:	PHYSICIANS INSURANCE A MUTUAL COMPANY
Employer identification number (EIN):	911160717
NAIC Classification:	524150