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SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 401k Plan overview

Plan NameSEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN
Plan identification number 505

SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN Benefits

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

401k Sponsoring company profile

THE BASEBALL CLUB OF SEATTLE, LLLP has sponsored the creation of one or more 401k plans.

Company Name:THE BASEBALL CLUB OF SEATTLE, LLLP
Employer identification number (EIN):911545344
NAIC Classification:711210
NAIC Description: Spectator Sports

Additional information about THE BASEBALL CLUB OF SEATTLE, LLLP

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 1992-01-23
Company Identification Number: 601363459
Legal Registered Office Address: 3400 CAPITOL BLVD SE STE 101

TUMWATER
United States of America (USA)
985013351

More information about THE BASEBALL CLUB OF SEATTLE, LLLP

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052022-01-01LISA WINSBY2023-06-01
5052021-01-01LISA WINSBY2022-10-08
5052020-01-01LISA WINSBY2021-07-07
5052019-01-01LISA WINSBY2020-10-12
5052019-01-01LISA WINSBY2021-01-08
5052018-01-01LISA M. WINSBY2019-09-24
5052017-01-01
5052016-01-01LISA WINSBY
5052015-01-01SHIRLEY SHREVE
5052014-01-01SHIRLEY SHREVE
5052014-01-01SHIRLEY SHREVE
5052013-01-01MARIANNE SHORT
5052012-01-01MARIANNE SHORT
5052011-01-01MARIANNE SHORT
5052009-01-01MARIANNE SHORT

Plan Statistics for SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN

401k plan membership statisitcs for SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN

Measure Date Value
2022: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01287
Total number of active participants reported on line 7a of the Form 55002022-01-01318
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01320
Number of employers contributing to the scheme2022-01-010
2021: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01315
Total number of active participants reported on line 7a of the Form 55002021-01-01284
Number of retired or separated participants receiving benefits2021-01-013
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01287
Number of employers contributing to the scheme2021-01-010
2020: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01344
Total number of active participants reported on line 7a of the Form 55002020-01-01289
Number of retired or separated participants receiving benefits2020-01-0126
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01315
Number of employers contributing to the scheme2020-01-010
2019: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01335
Total number of active participants reported on line 7a of the Form 55002019-01-01560
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01560
Number of employers contributing to the scheme2019-01-010
2018: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01303
Total number of active participants reported on line 7a of the Form 55002018-01-01335
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01335
Number of employers contributing to the scheme2018-01-010
2017: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01328
Total number of active participants reported on line 7a of the Form 55002017-01-01303
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01303
2016: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01270
Total number of active participants reported on line 7a of the Form 55002016-01-01328
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01328
2015: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01275
Total number of active participants reported on line 7a of the Form 55002015-01-01270
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01270
2014: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01271
Total number of active participants reported on line 7a of the Form 55002014-01-01275
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01275
2013: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01266
Total number of active participants reported on line 7a of the Form 55002013-01-01271
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01271
2012: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01261
Total number of active participants reported on line 7a of the Form 55002012-01-01266
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01266
2011: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01232
Total number of active participants reported on line 7a of the Form 55002011-01-01261
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01261
2009: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01225
Total number of active participants reported on line 7a of the Form 55002009-01-01224
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01224

Form 5500 Responses for SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN

2022: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: SEATTLE MARINERS MEDICAL, DENTAL, VISION AND PRESCRIPTION PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10249322
Policy instance 3
Insurance contract or identification number10249322
Number of Individuals Covered193
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $13,304
Total amount of fees paid to insurance companyUSD $5,959
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $88,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,304
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered46
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $948
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $948
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered318
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10249322
Policy instance 3
Insurance contract or identification number10249322
Number of Individuals Covered195
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $15,242
Total amount of fees paid to insurance companyUSD $2,995
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $101,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,242
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered46
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $910
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $910
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered560
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered560
Insurance policy start date2019-02-01
Insurance policy end date2020-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered47
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,015
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,015
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10249322
Policy instance 3
Insurance contract or identification number10249322
Number of Individuals Covered289
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $24,195
Total amount of fees paid to insurance companyUSD $6,877
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $161,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,195
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10249322
Policy instance 3
Insurance contract or identification number10249322
Number of Individuals Covered344
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $28,588
Total amount of fees paid to insurance companyUSD $8,503
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $190,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,588
Amount paid for insurance broker fees8503
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered47
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,069
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,069
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered560
Insurance policy start date2018-02-01
Insurance policy end date2019-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLK960900
Policy instance 3
Insurance contract or identification numberFLK960900
Number of Individuals Covered335
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $16,485
Total amount of fees paid to insurance companyUSD $1,260
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $109,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $16,485
Amount paid for insurance broker fees1260
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered27
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $578
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $578
Amount paid for insurance broker fees0
Insurance broker organization code?3
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered550
Insurance policy start date2017-02-01
Insurance policy end date2018-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLK960900
Policy instance 3
Insurance contract or identification numberFLK960900
Number of Individuals Covered530
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $29,081
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $193,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $29,081
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )
Policy contract numberWA521
Policy instance 2
Insurance contract or identification numberWA521
Number of Individuals Covered15
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $205
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $205
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered530
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $18,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 1
Insurance contract or identification number15965
Number of Individuals Covered270
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $28,582
Total amount of fees paid to insurance companyUSD $2,760
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $190,549
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,582
Insurance broker organization code?3
Amount paid for insurance broker fees2760
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker nameUSI INSURANCE SERVICES, LLC
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 2
Insurance contract or identification number00
Number of Individuals Covered530
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 2
Insurance contract or identification number15965
Number of Individuals Covered275
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $27,861
Total amount of fees paid to insurance companyUSD $3,142
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $371,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,861
Amount paid for insurance broker fees3142
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered530
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAND CREEK EAP (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered530
Insurance policy start date2013-02-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 2
Insurance contract or identification number15965
Number of Individuals Covered271
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $28,056
Total amount of fees paid to insurance companyUSD $8,342
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $187,039
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,056
Amount paid for insurance broker fees8342
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 2
Insurance contract or identification number15965
Number of Individuals Covered266
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $25,995
Total amount of fees paid to insurance companyUSD $12,299
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $173,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,995
Amount paid for insurance broker fees12299
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number61060
Policy instance 1
Insurance contract or identification number61060
Number of Individuals Covered518
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number61060
Policy instance 2
Insurance contract or identification number61060
Number of Individuals Covered518
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 1
Insurance contract or identification number15965
Number of Individuals Covered261
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $28,710
Total amount of fees paid to insurance companyUSD $2,010
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $191,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number850303
Policy instance 1
Insurance contract or identification number850303
Number of Individuals Covered27
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $545
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $545
Insurance broker organization code?3
Insurance broker nameJOHN SCOTTI
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number15965
Policy instance 2
Insurance contract or identification number15965
Number of Individuals Covered232
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $24,492
Total amount of fees paid to insurance companyUSD $10,162
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $163,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,492
Amount paid for insurance broker fees10162
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract numberEAP/WL
Policy instance 3
Insurance contract or identification numberEAP/WL
Number of Individuals Covered232
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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