SHELDON MANUFACTURING, INC. has sponsored the creation of one or more 401k plans.
Additional information about SHELDON MANUFACTURING, INC.
Submission information for form 5500 for 401k plan SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 113 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 113 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 133 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-02-01 | 0 |
| Total of all active and inactive participants | 2021-02-01 | 134 |
| Number of employers contributing to the scheme | 2021-02-01 | 0 |
| 2020: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 107 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 1 |
| Total of all active and inactive participants | 2020-02-01 | 109 |
| Number of employers contributing to the scheme | 2020-02-01 | 0 |
| 2019: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 125 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 126 |
| 2018: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 123 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Total of all active and inactive participants | 2018-02-01 | 124 |
| 2017: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 116 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 117 |
| 2016: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 114 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 115 |
| 2015: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 116 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 118 |
| 2014: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 118 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-02-01 | 0 |
| Total of all active and inactive participants | 2014-02-01 | 121 |
| 2013: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 118 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-02-01 | 0 |
| Total of all active and inactive participants | 2013-02-01 | 118 |
| 2012: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 123 |
| Number of retired or separated participants receiving benefits | 2012-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-02-01 | 0 |
| Total of all active and inactive participants | 2012-02-01 | 123 |
| 2011: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 131 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-08-01 | 0 |
| Total of all active and inactive participants | 2011-08-01 | 131 |
| 2010: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-08-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-08-01 | 144 |
| Number of retired or separated participants receiving benefits | 2010-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-08-01 | 0 |
| Total of all active and inactive participants | 2010-08-01 | 144 |
| 2009: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-08-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-08-01 | 144 |
| Number of retired or separated participants receiving benefits | 2009-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-08-01 | 0 |
| Total of all active and inactive participants | 2009-08-01 | 144 |
| 2008: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-08-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-08-01 | 175 |
| Number of retired or separated participants receiving benefits | 2008-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-08-01 | 0 |
| Total of all active and inactive participants | 2008-08-01 | 175 |
| 2022: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – Insurance | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | No |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-08-01 | Type of plan entity | Single employer plan |
| 2010-08-01 | Submission has been amended | No |
| 2010-08-01 | This submission is the final filing | No |
| 2010-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-08-01 | Plan is a collectively bargained plan | No |
| 2010-08-01 | Plan funding arrangement – Insurance | Yes |
| 2010-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-08-01 | Type of plan entity | Single employer plan |
| 2009-08-01 | Submission has been amended | No |
| 2009-08-01 | This submission is the final filing | No |
| 2009-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-08-01 | Plan is a collectively bargained plan | No |
| 2009-08-01 | Plan funding arrangement – Insurance | Yes |
| 2009-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: SHELDON MANUFACTURING, INC. HEALTH & WELFARE EMPLOYEE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-08-01 | Type of plan entity | Single employer plan |
| 2008-08-01 | First time form 5500 has been submitted | Yes |
| 2008-08-01 | Submission has been amended | No |
| 2008-08-01 | This submission is the final filing | No |
| 2008-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-08-01 | Plan is a collectively bargained plan | No |
| 2008-08-01 | Plan funding arrangement – Insurance | Yes |
| 2008-08-01 | Plan benefit arrangement – Insurance | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 4 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $9,345 | | Total amount of fees paid to insurance company | USD $809 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,345 | | Amount paid for insurance broker fees | 809 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20854 |
| Policy instance | 3 |
| Insurance contract or identification number | 20854 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $29,500 | | Total amount of fees paid to insurance company | USD $511 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $703,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,500 | | Amount paid for insurance broker fees | 511 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10016087 |
| Policy instance | 2 |
| Insurance contract or identification number | 10016087 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,656 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,656 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10159881001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10159881001 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $288 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $288 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10159881001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10159881001 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $517 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $517 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10016087 |
| Policy instance | 2 |
| Insurance contract or identification number | 10016087 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,022 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,022 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20854 |
| Policy instance | 3 |
| Insurance contract or identification number | 20854 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $10,860 | | Total amount of fees paid to insurance company | USD $469 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $610,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,860 | | Amount paid for insurance broker fees | 469 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 4 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,762 | | Total amount of fees paid to insurance company | USD $506 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,762 | | Amount paid for insurance broker fees | 506 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10159881001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10159881001 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $675 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,634 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $675 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10016087 |
| Policy instance | 2 |
| Insurance contract or identification number | 10016087 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $2,792 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,792 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20854 |
| Policy instance | 3 |
| Insurance contract or identification number | 20854 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $21,142 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $704,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,142 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 4 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $10,566 | | Total amount of fees paid to insurance company | USD $618 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,566 | | Amount paid for insurance broker fees | 618 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10159881001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10159881001 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $69 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $99 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10016087 |
| Policy instance | 2 |
| Insurance contract or identification number | 10016087 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $667 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,050 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $667 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 3 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $4,678 | | Total amount of fees paid to insurance company | USD $318 | | Long Term Disability 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 $2,544 | | Amount paid for insurance broker fees | 318 | | Additional information about fees paid to insurance broker | TOTAL CONTINGENT COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20854 |
| Policy instance | 4 |
| Insurance contract or identification number | 20854 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $15,356 | | Total amount of fees paid to insurance company | USD $4,000 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $636,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,356 | | Amount paid for insurance broker fees | 4000 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10016087 |
| Policy instance | 5 |
| Insurance contract or identification number | 10016087 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $1,979 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,658 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,979 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 6 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $2,601 | | Total amount of fees paid to insurance company | USD $241 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,409 | | Amount paid for insurance broker fees | 241 | | Additional information about fees paid to insurance broker | TOTAL CONTINGENT COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 5 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $2,387 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,387 | | Insurance broker organization code? | 3 | | Insurance broker name | WALTZ SHERIDAN CRAWFORD INC. |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139/Z243 |
| Policy instance | 4 |
| Insurance contract or identification number | OR139/Z243 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,024 | | 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 | | Commission paid to Insurance Broker | USD $2,024 | | Insurance broker organization code? | 3 | | Insurance broker name | WSC BENEFIT SPECIALISTS |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139/Z243 |
| Policy instance | 3 |
| Insurance contract or identification number | OR139/Z243 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $160 | | 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 | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 | | Insurance broker name | WSC BENEFIT SPECIALISTS |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20854 |
| Policy instance | 2 |
| Insurance contract or identification number | 20854 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $13,314 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $534,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,314 | | Insurance broker organization code? | 3 | | Insurance broker name | WSC BENEFIT SPECIALISTS |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 1 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $3,928 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $3,928 | | Insurance broker organization code? | 3 | | Insurance broker name | WALTZ SHERIDAN CRAWFORD INC. |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139/Z243 |
| Policy instance | 4 |
| Insurance contract or identification number | OR139/Z243 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,720 | | 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 | | Commission paid to Insurance Broker | USD $1,720 | | Insurance broker organization code? | 3 | | Insurance broker name | HKW INSURANCE AGENCY |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | ORLG100274 |
| Policy instance | 3 |
| Insurance contract or identification number | ORLG100274 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $13,445 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $502,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,445 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 2 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,989 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $2,989 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 1 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,224 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,224 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139 |
| Policy instance | 1 |
| Insurance contract or identification number | OR139 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | ORLG100274 |
| Policy instance | 2 |
| Insurance contract or identification number | ORLG100274 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $13,902 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $488,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,902 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 3 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,668 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,668 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 847451 |
| Policy instance | 4 |
| Insurance contract or identification number | 847451 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $2,256 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $2,256 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 4 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $1,659 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,659 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | ORLG100274 |
| Policy instance | 3 |
| Insurance contract or identification number | ORLG100274 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $9,290 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $272,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,290 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139 |
| Policy instance | 2 |
| Insurance contract or identification number | OR139 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 1 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $2,345 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $2,345 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 1 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $2,426 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $2,426 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | ORLG100274 |
| Policy instance | 2 |
| Insurance contract or identification number | ORLG100274 | | Number of Individuals Covered | 405 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $18,934 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $923,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,934 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 3 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $1,362 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,362 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139 |
| Policy instance | 4 |
| Insurance contract or identification number | OR139 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 1 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-01-31 | | Total amount of commissions paid to insurance broker | USD $1,933 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability 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 $1,933 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 147451 |
| Policy instance | 2 |
| Insurance contract or identification number | 147451 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-01-31 | | Total amount of commissions paid to insurance broker | USD $1,085 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,085 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139 |
| Policy instance | 3 |
| Insurance contract or identification number | OR139 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 100274 |
| Policy instance | 4 |
| Insurance contract or identification number | 100274 | | Number of Individuals Covered | 405 | | Insurance policy start date | 2009-08-01 | | Insurance policy end date | 2010-07-31 | | Total amount of commissions paid to insurance broker | USD $17,101 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $768,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,101 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 584209 |
| Policy instance | 4 |
| Insurance contract or identification number | 584209 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $3,911 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $32,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,911 | | Insurance broker organization code? | 3 | | Insurance broker name | FULLERTON & COMPANY INSURANCE AGCY |
|
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
| Policy contract number | OR139 |
| Policy instance | 3 |
| Insurance contract or identification number | OR139 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 100274 |
| Policy instance | 2 |
| Insurance contract or identification number | 100274 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2008-08-01 | | Insurance policy end date | 2009-07-31 | | Total amount of commissions paid to insurance broker | USD $21,146 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,176,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,146 | | Insurance broker organization code? | 3 | | Insurance broker name | THIPPAYAPHORN SUKHEENAI |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 584209 |
| Policy instance | 1 |
| Insurance contract or identification number | 584209 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-04-01 | | Total amount of commissions paid to insurance broker | USD $1,284 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,809 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,284 | | Insurance broker organization code? | 3 | | Insurance broker name | FULLERTON & COMPANY INSURNACE AGCY |
|
