OLYMPIC BENEFITS TRUST has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022 : OLYMPIC BENEFITS TRUST 2022 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2022-12-31 | $-50,036 |
| Total unrealized appreciation/depreciation of assets | 2022-12-31 | $-50,036 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $26,273 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $74,637 |
| Total income from all sources (including contributions) | 2022-12-31 | $1,787,488 |
| Total loss/gain on sale of assets | 2022-12-31 | $0 |
| Total of all expenses incurred | 2022-12-31 | $1,823,494 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $1,694,589 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $1,833,133 |
| Value of total assets at end of year | 2022-12-31 | $235,296 |
| Value of total assets at beginning of year | 2022-12-31 | $319,666 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $128,905 |
| Total interest from all sources | 2022-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-12-31 | $4,391 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2022-12-31 | $4,391 |
| Administrative expenses professional fees incurred | 2022-12-31 | $47,262 |
| Was this plan covered by a fidelity bond | 2022-12-31 | Yes |
| Value of fidelity bond cover | 2022-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Participant contributions at end of year | 2022-12-31 | $28,953 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $1,202 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $15,729 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-12-31 | $19,113 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-12-31 | $55,805 |
| Administrative expenses (other) incurred | 2022-12-31 | $8,100 |
| Liabilities. Value of operating payables at end of year | 2022-12-31 | $7,160 |
| Liabilities. Value of operating payables at beginning of year | 2022-12-31 | $18,832 |
| Total non interest bearing cash at end of year | 2022-12-31 | $3,071 |
| Total non interest bearing cash at beginning of year | 2022-12-31 | $16,221 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Income. Non cash contributions | 2022-12-31 | $13,834 |
| Value of net income/loss | 2022-12-31 | $-36,006 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $209,023 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $245,029 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Investment advisory and management fees | 2022-12-31 | $15,985 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-12-31 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $1,694,589 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $1,819,299 |
| Asset. Corporate debt instrument preferred debt at end of year | 2022-12-31 | $72,738 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2022-12-31 | $106,855 |
| Asset. Corporate debt instrument debt (other) at end of year | 2022-12-31 | $129,332 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2022-12-31 | $180,861 |
| Contract administrator fees | 2022-12-31 | $57,558 |
| Did the plan have assets held for investment | 2022-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | LINDLEY & ASSOCIATES LLC |
| Accountancy firm EIN | 2022-12-31 | 912050235 |
| 2021 : OLYMPIC BENEFITS TRUST 2021 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2021-12-31 | $20,422 |
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $20,422 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $74,637 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $82,715 |
| Total income from all sources (including contributions) | 2021-12-31 | $2,065,932 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $2,037,634 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $1,919,441 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $2,036,842 |
| Value of total assets at end of year | 2021-12-31 | $319,666 |
| Value of total assets at beginning of year | 2021-12-31 | $299,446 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $118,193 |
| Total interest from all sources | 2021-12-31 | $1 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $8,667 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Total dividends received from registered investment company shares (eg mutual funds) | 2021-12-31 | $8,667 |
| Administrative expenses professional fees incurred | 2021-12-31 | $25,475 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Participant contributions at beginning of year | 2021-12-31 | $0 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $15,729 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $6,010 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $55,805 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-12-31 | $69,254 |
| Administrative expenses (other) incurred | 2021-12-31 | $11,684 |
| Total non interest bearing cash at end of year | 2021-12-31 | $16,221 |
| Total non interest bearing cash at beginning of year | 2021-12-31 | $100 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Income. Non cash contributions | 2021-12-31 | $15,088 |
| Value of net income/loss | 2021-12-31 | $28,298 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $245,029 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $216,731 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Investment advisory and management fees | 2021-12-31 | $19,128 |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2021-12-31 | $0 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2021-12-31 | $0 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-12-31 | $0 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-12-31 | $8,808 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-12-31 | $8,808 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-12-31 | $1 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $2,021,754 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $1,919,441 |
| Asset. Corporate debt instrument preferred debt at end of year | 2021-12-31 | $106,855 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2021-12-31 | $73,568 |
| Asset. Corporate debt instrument debt (other) at end of year | 2021-12-31 | $180,861 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2021-12-31 | $210,960 |
| Contract administrator fees | 2021-12-31 | $61,906 |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $18,832 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $13,461 |
| Did the plan have assets held for investment | 2021-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Disclaimer |
| Accountancy firm name | 2021-12-31 | LINDLEY & ASSOCIATES LLC |
| Accountancy firm EIN | 2021-12-31 | 912050235 |
| 2020 : OLYMPIC BENEFITS TRUST 2020 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2020-12-31 | $36,409 |
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $36,409 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $82,715 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $74,476 |
| Total income from all sources (including contributions) | 2020-12-31 | $2,154,423 |
| Total loss/gain on sale of assets | 2020-12-31 | $489 |
| Total of all expenses incurred | 2020-12-31 | $2,141,399 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $2,006,614 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $2,112,060 |
| Value of total assets at end of year | 2020-12-31 | $299,446 |
| Value of total assets at beginning of year | 2020-12-31 | $278,183 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $134,785 |
| Total interest from all sources | 2020-12-31 | $143 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $5,322 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Administrative expenses professional fees incurred | 2020-12-31 | $52,478 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $6,010 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $1,722 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-12-31 | $82,715 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-12-31 | $74,476 |
| Administrative expenses (other) incurred | 2020-12-31 | $11,013 |
| Total non interest bearing cash at end of year | 2020-12-31 | $100 |
| Total non interest bearing cash at beginning of year | 2020-12-31 | $14,053 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $13,024 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $216,731 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $203,707 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Investment advisory and management fees | 2020-12-31 | $3,490 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-12-31 | $8,808 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-12-31 | $3,123 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-12-31 | $3,123 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-12-31 | $143 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $2,006,614 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $2,112,060 |
| Income. Dividends from preferred stock | 2020-12-31 | $5,322 |
| Asset. Corporate debt instrument preferred debt at end of year | 2020-12-31 | $73,568 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2020-12-31 | $87,060 |
| Asset. Corporate debt instrument debt (other) at end of year | 2020-12-31 | $210,960 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2020-12-31 | $175,348 |
| Contract administrator fees | 2020-12-31 | $67,804 |
| Did the plan have assets held for investment | 2020-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Aggregate proceeds on sale of assets | 2020-12-31 | $489 |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2020-12-31 | 910950090 |
| 2019 : OLYMPIC BENEFITS TRUST 2019 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2019-12-31 | $31,770 |
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $31,770 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $72,181 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $79,267 |
| Total income from all sources (including contributions) | 2019-12-31 | $2,396,044 |
| Total loss/gain on sale of assets | 2019-12-31 | $6,817 |
| Total of all expenses incurred | 2019-12-31 | $2,360,319 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $2,208,726 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $2,352,008 |
| Value of total assets at end of year | 2019-12-31 | $278,183 |
| Value of total assets at beginning of year | 2019-12-31 | $249,544 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $151,593 |
| Total interest from all sources | 2019-12-31 | $250 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $5,199 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Administrative expenses professional fees incurred | 2019-12-31 | $52,613 |
| Was this plan covered by a fidelity bond | 2019-12-31 | Yes |
| Value of fidelity bond cover | 2019-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Assets. Other investments not covered elsewhere at beginning of year | 2019-12-31 | $19 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $1,722 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2019-12-31 | $1,536 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2019-12-31 | $72,181 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2019-12-31 | $79,267 |
| Administrative expenses (other) incurred | 2019-12-31 | $10,800 |
| Total non interest bearing cash at end of year | 2019-12-31 | $10,930 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $14,384 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Income. Non cash contributions | 2019-12-31 | $0 |
| Value of net income/loss | 2019-12-31 | $35,725 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $206,002 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $170,277 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Investment advisory and management fees | 2019-12-31 | $2,860 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-12-31 | $3,123 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-12-31 | $14,999 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-12-31 | $14,999 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2019-12-31 | $250 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $2,208,726 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $2,352,008 |
| Income. Dividends from preferred stock | 2019-12-31 | $5,199 |
| Asset. Corporate debt instrument preferred debt at end of year | 2019-12-31 | $87,060 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2019-12-31 | $63,289 |
| Asset. Corporate debt instrument debt (other) at end of year | 2019-12-31 | $175,348 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2019-12-31 | $155,317 |
| Contract administrator fees | 2019-12-31 | $85,320 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $0 |
| Assets. Value of buildings and other operty used in plan operation at end of year | 2019-12-31 | $0 |
| Assets. Value of buildings and other operty used in plan operation at beginning of year | 2019-12-31 | $0 |
| Did the plan have assets held for investment | 2019-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Aggregate proceeds on sale of assets | 2019-12-31 | $6,817 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Accountancy firm name | 2019-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2019-12-31 | 910950090 |
| 2018 : OLYMPIC BENEFITS TRUST 2018 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2018-12-31 | $-34,228 |
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $-34,228 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $79,267 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $53,419 |
| Total income from all sources (including contributions) | 2018-12-31 | $2,270,826 |
| Total loss/gain on sale of assets | 2018-12-31 | $7,443 |
| Total of all expenses incurred | 2018-12-31 | $2,314,387 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $2,198,770 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $2,290,977 |
| Value of total assets at end of year | 2018-12-31 | $248,026 |
| Value of total assets at beginning of year | 2018-12-31 | $265,739 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $115,617 |
| Total interest from all sources | 2018-12-31 | $277 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $6,357 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Administrative expenses professional fees incurred | 2018-12-31 | $26,585 |
| Was this plan covered by a fidelity bond | 2018-12-31 | Yes |
| Value of fidelity bond cover | 2018-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2018-12-31 | $38 |
| Assets. Other investments not covered elsewhere at beginning of year | 2018-12-31 | $122 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-12-31 | $14,999 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-12-31 | $19,987 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2018-12-31 | $79,267 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2018-12-31 | $53,419 |
| Other income not declared elsewhere | 2018-12-31 | $0 |
| Administrative expenses (other) incurred | 2018-12-31 | $10,738 |
| Total non interest bearing cash at end of year | 2018-12-31 | $14,384 |
| Total non interest bearing cash at beginning of year | 2018-12-31 | $6,686 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $-43,561 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $168,759 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $212,320 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Investment advisory and management fees | 2018-12-31 | $2,876 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2018-12-31 | $277 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $2,198,770 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $2,290,977 |
| Income. Dividends from preferred stock | 2018-12-31 | $6,357 |
| Asset. Corporate debt instrument preferred debt at end of year | 2018-12-31 | $63,288 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2018-12-31 | $53,112 |
| Asset. Corporate debt instrument debt (other) at end of year | 2018-12-31 | $155,317 |
| Asset. Corporate debt instrument debt (other) at beginning of year | 2018-12-31 | $185,832 |
| Contract administrator fees | 2018-12-31 | $75,418 |
| Did the plan have assets held for investment | 2018-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Aggregate proceeds on sale of assets | 2018-12-31 | $7,443 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
| Accountancy firm name | 2018-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2018-12-31 | 910950090 |
| 2017 : OLYMPIC BENEFITS TRUST 2017 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2017-12-31 | $30,912 |
| Total unrealized appreciation/depreciation of assets | 2017-12-31 | $30,912 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $53,419 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-12-31 | $105,785 |
| Total income from all sources (including contributions) | 2017-12-31 | $2,530,992 |
| Total loss/gain on sale of assets | 2017-12-31 | $3,585 |
| Total of all expenses incurred | 2017-12-31 | $2,447,531 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $2,336,449 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $2,491,954 |
| Value of total assets at end of year | 2017-12-31 | $267,256 |
| Value of total assets at beginning of year | 2017-12-31 | $236,161 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $111,082 |
| Total interest from all sources | 2017-12-31 | $155 |
| Total dividends received (eg from common stock, registered investment company shares) | 2017-12-31 | $4,386 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Administrative expenses professional fees incurred | 2017-12-31 | $24,944 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2017-12-31 | $53,112 |
| Assets. Corporate prefeered stocks other than exployer securities at beginning of year | 2017-12-31 | $56,974 |
| Was this plan covered by a fidelity bond | 2017-12-31 | Yes |
| Value of fidelity bond cover | 2017-12-31 | $270,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2017-12-31 | $122 |
| Assets. Other investments not covered elsewhere at beginning of year | 2017-12-31 | $87 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2017-12-31 | $1,518 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2017-12-31 | $53,419 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2017-12-31 | $105,785 |
| Administrative expenses (other) incurred | 2017-12-31 | $10,080 |
| Total non interest bearing cash at end of year | 2017-12-31 | $6,685 |
| Total non interest bearing cash at beginning of year | 2017-12-31 | $15,776 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $83,461 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $213,837 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $130,376 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Investment advisory and management fees | 2017-12-31 | $2,583 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-12-31 | $19,987 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-12-31 | $19,994 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-12-31 | $19,994 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-12-31 | $155 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $2,336,449 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $2,491,954 |
| Income. Dividends from preferred stock | 2017-12-31 | $4,386 |
| Contract administrator fees | 2017-12-31 | $73,475 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2017-12-31 | $185,832 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2017-12-31 | $143,330 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-12-31 | $0 |
| Did the plan have assets held for investment | 2017-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Aggregate proceeds on sale of assets | 2017-12-31 | $3,585 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2017-12-31 | 910950090 |
| 2016 : OLYMPIC BENEFITS TRUST 2016 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2016-12-31 | $8,276 |
| Total unrealized appreciation/depreciation of assets | 2016-12-31 | $8,276 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $105,785 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-12-31 | $98,429 |
| Total income from all sources (including contributions) | 2016-12-31 | $2,632,761 |
| Total loss/gain on sale of assets | 2016-12-31 | $-963 |
| Total of all expenses incurred | 2016-12-31 | $2,629,842 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $2,517,026 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $2,620,726 |
| Value of total assets at end of year | 2016-12-31 | $236,161 |
| Value of total assets at beginning of year | 2016-12-31 | $225,886 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $112,816 |
| Total interest from all sources | 2016-12-31 | $159 |
| Total dividends received (eg from common stock, registered investment company shares) | 2016-12-31 | $4,563 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Administrative expenses professional fees incurred | 2016-12-31 | $23,996 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2016-12-31 | $56,974 |
| Assets. Corporate prefeered stocks other than exployer securities at beginning of year | 2016-12-31 | $29,004 |
| Was this plan covered by a fidelity bond | 2016-12-31 | Yes |
| Value of fidelity bond cover | 2016-12-31 | $30,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2016-12-31 | $87 |
| Assets. Other investments not covered elsewhere at beginning of year | 2016-12-31 | $508 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2016-12-31 | $1,470 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2016-12-31 | $105,785 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2016-12-31 | $98,429 |
| Administrative expenses (other) incurred | 2016-12-31 | $10,080 |
| Total non interest bearing cash at end of year | 2016-12-31 | $15,776 |
| Total non interest bearing cash at beginning of year | 2016-12-31 | $24,725 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $2,919 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $130,376 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $127,457 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Investment advisory and management fees | 2016-12-31 | $2,177 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $19,994 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $19,984 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $19,984 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $159 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $2,517,026 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $2,620,726 |
| Income. Dividends from preferred stock | 2016-12-31 | $4,563 |
| Contract administrator fees | 2016-12-31 | $76,563 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2016-12-31 | $143,330 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2016-12-31 | $150,195 |
| Did the plan have assets held for investment | 2016-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Aggregate proceeds on sale of assets | 2016-12-31 | $-963 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Unqualified |
| Accountancy firm name | 2016-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2016-12-31 | 910950090 |
| 2015 : OLYMPIC BENEFITS TRUST 2015 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2015-12-31 | $-25,419 |
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $-25,419 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $840 |
| Total income from all sources (including contributions) | 2015-12-31 | $2,522,476 |
| Total loss/gain on sale of assets | 2015-12-31 | $4,087 |
| Total of all expenses incurred | 2015-12-31 | $2,533,479 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $2,424,125 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $2,513,532 |
| Value of total assets at end of year | 2015-12-31 | $225,885 |
| Value of total assets at beginning of year | 2015-12-31 | $237,728 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $109,354 |
| Total interest from all sources | 2015-12-31 | $26 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $12,760 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Administrative expenses professional fees incurred | 2015-12-31 | $22,504 |
| Assets. Corporate prefeered stocks other than exployer securities at end of year | 2015-12-31 | $29,004 |
| Was this plan covered by a fidelity bond | 2015-12-31 | Yes |
| Value of fidelity bond cover | 2015-12-31 | $30,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2015-12-31 | $507 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2015-12-31 | $1,470 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-12-31 | $2,643 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2015-12-31 | $840 |
| Other income not declared elsewhere | 2015-12-31 | $17,490 |
| Administrative expenses (other) incurred | 2015-12-31 | $10,080 |
| Total non interest bearing cash at end of year | 2015-12-31 | $24,725 |
| Total non interest bearing cash at beginning of year | 2015-12-31 | $25,605 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $-11,003 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $225,885 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $236,888 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Investment advisory and management fees | 2015-12-31 | $3,159 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $19,984 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-12-31 | $26 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $2,424,125 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $2,513,532 |
| Income. Dividends from preferred stock | 2015-12-31 | $12,760 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2015-12-31 | $76,483 |
| Contract administrator fees | 2015-12-31 | $73,611 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2015-12-31 | $150,195 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2015-12-31 | $132,997 |
| Did the plan have assets held for investment | 2015-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Aggregate proceeds on sale of assets | 2015-12-31 | $4,087 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | N R SMITH AND ASSOCIATES |
| Accountancy firm EIN | 2015-12-31 | 910950090 |
| 2014 : OLYMPIC BENEFITS TRUST 2014 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2014-12-31 | $-19,514 |
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $-19,514 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $840 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $1,251 |
| Total income from all sources (including contributions) | 2014-12-31 | $2,417,507 |
| Total loss/gain on sale of assets | 2014-12-31 | $15,419 |
| Total of all expenses incurred | 2014-12-31 | $2,413,774 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $2,320,337 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $2,407,213 |
| Value of total assets at end of year | 2014-12-31 | $237,728 |
| Value of total assets at beginning of year | 2014-12-31 | $234,406 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $93,437 |
| Total interest from all sources | 2014-12-31 | $259 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $14,130 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Administrative expenses professional fees incurred | 2014-12-31 | $22,214 |
| Was this plan covered by a fidelity bond | 2014-12-31 | Yes |
| Value of fidelity bond cover | 2014-12-31 | $30,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-12-31 | $2,643 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-12-31 | $5,400 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2014-12-31 | $840 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2014-12-31 | $1,251 |
| Administrative expenses (other) incurred | 2014-12-31 | $11,640 |
| Total non interest bearing cash at end of year | 2014-12-31 | $25,605 |
| Total non interest bearing cash at beginning of year | 2014-12-31 | $16,970 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $3,733 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $236,888 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $233,155 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Investment advisory and management fees | 2014-12-31 | $3,266 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-12-31 | $259 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $2,320,337 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $2,407,213 |
| Income. Dividends from preferred stock | 2014-12-31 | $14,130 |
| Asset. Corporate debt instrument preferred debt at end of year | 2014-12-31 | $76,483 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2014-12-31 | $80,029 |
| Contract administrator fees | 2014-12-31 | $56,317 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2014-12-31 | $132,997 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2014-12-31 | $132,007 |
| Did the plan have assets held for investment | 2014-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Aggregate proceeds on sale of assets | 2014-12-31 | $15,419 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Unqualified |
| Accountancy firm name | 2014-12-31 | N R SMITH AND ASSOCIATES, PS |
| Accountancy firm EIN | 2014-12-31 | 910950090 |
| 2013 : OLYMPIC BENEFITS TRUST 2013 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2013-12-31 | $16,768 |
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $16,768 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $1,251 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $0 |
| Total income from all sources (including contributions) | 2013-12-31 | $2,183,072 |
| Total loss/gain on sale of assets | 2013-12-31 | $6,121 |
| Total of all expenses incurred | 2013-12-31 | $2,171,205 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $2,070,099 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $2,147,407 |
| Value of total assets at end of year | 2013-12-31 | $234,406 |
| Value of total assets at beginning of year | 2013-12-31 | $221,288 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $101,106 |
| Total interest from all sources | 2013-12-31 | $496 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $12,280 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Administrative expenses professional fees incurred | 2013-12-31 | $24,373 |
| Was this plan covered by a fidelity bond | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-12-31 | $5,400 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-12-31 | $9,687 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2013-12-31 | $1,251 |
| Administrative expenses (other) incurred | 2013-12-31 | $25,584 |
| Total non interest bearing cash at end of year | 2013-12-31 | $16,970 |
| Total non interest bearing cash at beginning of year | 2013-12-31 | $16,056 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $11,867 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $233,155 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $221,288 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Investment advisory and management fees | 2013-12-31 | $3,153 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-12-31 | $496 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $2,070,099 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $2,147,407 |
| Income. Dividends from common stock | 2013-12-31 | $12,280 |
| Asset. Corporate debt instrument preferred debt at end of year | 2013-12-31 | $80,029 |
| Asset. Corporate debt instrument preferred debt at beginning of year | 2013-12-31 | $86,720 |
| Contract administrator fees | 2013-12-31 | $47,996 |
| Assets. Corporate common stocks other than exployer securities at end of year | 2013-12-31 | $132,007 |
| Assets. Corporate common stocks other than exployer securities at beginning of year | 2013-12-31 | $108,825 |
| Did the plan have assets held for investment | 2013-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Aggregate proceeds on sale of assets | 2013-12-31 | $6,121 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Unqualified |
| Accountancy firm name | 2013-12-31 | N R SMITH & ASSOCIATES, PS |
| Accountancy firm EIN | 2013-12-31 | 910950090 |
| 2011 : OLYMPIC BENEFITS TRUST 2011 401k financial data |
|---|
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-12-31 | $2,943 |
| Total income from all sources (including contributions) | 2011-12-31 | $5,113,847 |
| Total loss/gain on sale of assets | 2011-12-31 | $4,348 |
| Total of all expenses incurred | 2011-12-31 | $5,121,365 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $4,981,609 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $5,099,669 |
| Value of total assets at end of year | 2011-12-31 | $235,536 |
| Value of total assets at beginning of year | 2011-12-31 | $256,757 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $139,756 |
| Total interest from all sources | 2011-12-31 | $9,830 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Administrative expenses professional fees incurred | 2011-12-31 | $24,489 |
| Was this plan covered by a fidelity bond | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2011-12-31 | $-2,742 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2011-12-31 | $7,940 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2011-12-31 | $6,386 |
| Assets. Loans (other than to participants) at end of year | 2011-12-31 | $6,162 |
| Assets. Loans (other than to participants) at beginning of year | 2011-12-31 | $16,327 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2011-12-31 | $2,943 |
| Administrative expenses (other) incurred | 2011-12-31 | $45,998 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $-7,518 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $235,536 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $253,814 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2011-12-31 | $204,821 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2011-12-31 | $211,048 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $16,613 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $22,996 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $22,996 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $9,830 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $4,984,351 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $5,099,669 |
| Contract administrator fees | 2011-12-31 | $69,269 |
| Did the plan have assets held for investment | 2011-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Aggregate proceeds on sale of assets | 2011-12-31 | $4,348 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Unqualified |
| Accountancy firm name | 2011-12-31 | N R SMITH & ASSOCIATES, PS |
| Accountancy firm EIN | 2011-12-31 | 910950090 |
| 2010 : OLYMPIC BENEFITS TRUST 2010 401k financial data |
|---|
| Unrealized appreciation/depreciation of other (non real estate) assets | 2010-12-31 | $13,174 |
| Total unrealized appreciation/depreciation of assets | 2010-12-31 | $13,174 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $2,943 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2010-12-31 | $16,815 |
| Total income from all sources (including contributions) | 2010-12-31 | $12,476,925 |
| Total loss/gain on sale of assets | 2010-12-31 | $3,454 |
| Total of all expenses incurred | 2010-12-31 | $12,441,818 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $12,171,078 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $12,451,739 |
| Value of total assets at end of year | 2010-12-31 | $256,757 |
| Value of total assets at beginning of year | 2010-12-31 | $235,522 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $270,740 |
| Total interest from all sources | 2010-12-31 | $8,558 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Administrative expenses professional fees incurred | 2010-12-31 | $34,042 |
| Was this plan covered by a fidelity bond | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Assets. Other investments not covered elsewhere at end of year | 2010-12-31 | $0 |
| Assets. Other investments not covered elsewhere at beginning of year | 2010-12-31 | $1,524 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2010-12-31 | $4,467 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2010-12-31 | $6,386 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2010-12-31 | $17,405 |
| Assets. Loans (other than to participants) at end of year | 2010-12-31 | $16,327 |
| Assets. Loans (other than to participants) at beginning of year | 2010-12-31 | $26,492 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2010-12-31 | $2,943 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2010-12-31 | $0 |
| Administrative expenses (other) incurred | 2010-12-31 | $52,109 |
| Liabilities. Value of operating payables at end of year | 2010-12-31 | $0 |
| Liabilities. Value of operating payables at beginning of year | 2010-12-31 | $16,815 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $35,107 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $253,814 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $218,707 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Value of interest in registered invesment companies (eg mutual funds) at end of year | 2010-12-31 | $211,048 |
| Value of interest in registered invesment companies (eg mutual funds) at beginning of year | 2010-12-31 | $175,584 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2010-12-31 | $22,996 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2010-12-31 | $14,517 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2010-12-31 | $14,517 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2010-12-31 | $8,558 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2010-12-31 | $12,166,611 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $12,451,739 |
| Contract administrator fees | 2010-12-31 | $184,589 |
| Did the plan have assets held for investment | 2010-12-31 | Yes |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Aggregate proceeds on sale of assets | 2010-12-31 | $3,454 |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Unqualified |
| Accountancy firm name | 2010-12-31 | N R SMITH & ASSOCIATES, PS |
| Accountancy firm EIN | 2010-12-31 | 910950090 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 07114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 714 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 07114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 810 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 1 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 1855 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $117,846 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Commission paid to Insurance Broker | USD $117,846 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 2 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 1855 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $117,846 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Commission paid to Insurance Broker | USD $117,846 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 07114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 782 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 1 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2017 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $151,733 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $151,733 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 07114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 782 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 2 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2017 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $151,733 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $151,733 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 07114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 822 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 2 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2117 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $125,282 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $125,282 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 1 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2117 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $125,282 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 07114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 822 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 1 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2189 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $142,041 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $142,041 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 2 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2189 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $142,041 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $142,041 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 7114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 7114519 | | Number of Individuals Covered | 1944 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 7114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 7114519 | | Number of Individuals Covered | 1944 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 00628 |
| Policy instance | 1 |
| Insurance contract or identification number | 00628 | | Number of Individuals Covered | 2305 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $137,233 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $137,233 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 7114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 7114519 | | Number of Individuals Covered | 736 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 1 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 2365 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $159,359 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $159,359 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 2 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 2365 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $159,359 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $159,359 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 7114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 7114519 | | Number of Individuals Covered | 701 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 7114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 7114519 | | Number of Individuals Covered | 701 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 1 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 2775 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $150,990 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 | 07114519-10-11 |
| Policy instance | 2 |
| Insurance contract or identification number | 07114519-10-11 | | Number of Individuals Covered | 754 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 2 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 2687 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $156,011 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $156,011 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 07114519 |
| Policy instance | 1 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 756 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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: 47317 ) |
| Policy contract number | 07114519 |
| Policy instance | 2 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 1 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 2378 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $138,907 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $138,907 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES, INC. |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | CBS GROUPS |
| Policy instance | 2 |
| Insurance contract or identification number | CBS GROUPS | | Number of Individuals Covered | 125 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $22,638 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $188,647 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,638 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 15092 | | Additional information about fees paid to insurance broker | BILLING FEES | | Insurance broker name | IHC HEALTH SOLUTIONS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 07114519 |
| Policy instance | 7 |
| Insurance contract or identification number | 07114519 | | Number of Individuals Covered | 753 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | WDS-628 |
| Policy instance | 1 |
| Insurance contract or identification number | WDS-628 | | Number of Individuals Covered | 2095 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $121,644 | | 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 $121,644 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010102115 |
| Policy instance | 6 |
| Insurance contract or identification number | 000010102115 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $236 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $236 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES, INC. |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6338200 |
| Policy instance | 5 |
| Insurance contract or identification number | 6338200 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $871 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,423 |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6269500 |
| Policy instance | 4 |
| Insurance contract or identification number | 6269500 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $7,481 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $149,638 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,481 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES, INC. |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 5273600 |
| Policy instance | 3 |
| Insurance contract or identification number | 5273600 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,194 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,194 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST MARKETING RESOURCES, INC. |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | ALL CBS GROUPS |
| Policy instance | 5 |
| Insurance contract or identification number | ALL CBS GROUPS | | Number of Individuals Covered | 377 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $33,402 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $278,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 16534 |
| Policy instance | 6 |
| Insurance contract or identification number | 16534 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $785 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 5273600 |
| Policy instance | 1 |
| Insurance contract or identification number | 5273600 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $6,438 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $128,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6269400 |
| Policy instance | 2 |
| Insurance contract or identification number | 6269400 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,409 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KPS HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 53872 ) |
| Policy contract number | VARIOUS |
| Policy instance | 7 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 455 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $132,599 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,516,105 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010102115 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010102115 | | Number of Individuals Covered | 506 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,246 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6269500 |
| Policy instance | 3 |
| Insurance contract or identification number | 6269500 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $19,279 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $385,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 9 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 1878 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $109,846 | | Dental Insurance Welfare Benefit | Yes | | 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: 47317 ) |
| Policy contract number | 07114519 4 6 |
| Policy instance | 10 |
| Insurance contract or identification number | 07114519 4 6 | | Number of Individuals Covered | 809 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6338200 |
| Policy instance | 4 |
| Insurance contract or identification number | 6338200 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $671 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,410 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010102115 |
| Policy instance | 9 |
| Insurance contract or identification number | 000010102115 | | Number of Individuals Covered | 2007 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $10,935 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $72,903 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 5273600 |
| Policy instance | 1 |
| Insurance contract or identification number | 5273600 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $11,376 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $228,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6269500 |
| Policy instance | 2 |
| Insurance contract or identification number | 6269500 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $16,007 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $319,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6338200 |
| Policy instance | 3 |
| Insurance contract or identification number | 6338200 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $91 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
| Policy contract number | 6269400 |
| Policy instance | 4 |
| Insurance contract or identification number | 6269400 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $36,993 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $743,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 16534 |
| Policy instance | 5 |
| Insurance contract or identification number | 16534 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $484 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KPS HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 53872 ) |
| Policy contract number | VARIOUS |
| Policy instance | 6 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 1854 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $598,237 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,203,645 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
| Policy contract number | 628 |
| Policy instance | 8 |
| Insurance contract or identification number | 628 | | Number of Individuals Covered | 1573 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $92,050 | | 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 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 07114519 4 6 |
| Policy instance | 10 |
| Insurance contract or identification number | 07114519 4 6 | | Number of Individuals Covered | 1098 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | VARIOUS |
| Policy instance | 7 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 521 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $31,486 | | Total amount of fees paid to insurance company | USD $20,991 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $262,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
