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WHITE BIRD CLINIC HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameWHITE BIRD CLINIC HEALTH AND WELFARE PLAN
Plan identification number 501

WHITE BIRD CLINIC HEALTH AND WELFARE PLAN Benefits

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WHITE BIRD CLINIC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01JEREMY GATES2023-06-07
5012021-01-01CHRIS HECHT2022-05-11
5012020-01-01CHRIS HECHT2022-05-11

Plan Statistics for WHITE BIRD CLINIC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for WHITE BIRD CLINIC HEALTH AND WELFARE PLAN

Measure Date Value
2022: WHITE BIRD CLINIC HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01126
Total number of active participants reported on line 7a of the Form 55002022-01-01136
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01136
Number of employers contributing to the scheme2022-01-010
2021: WHITE BIRD CLINIC HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01126
Total number of active participants reported on line 7a of the Form 55002021-01-01126
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01126
Number of employers contributing to the scheme2021-01-010
2020: WHITE BIRD CLINIC HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01125
Total number of active participants reported on line 7a of the Form 55002020-01-01126
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01126
Number of employers contributing to the scheme2020-01-010

Form 5500 Responses for WHITE BIRD CLINIC HEALTH AND WELFARE PLAN

2022: WHITE BIRD CLINIC HEALTH AND WELFARE 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: WHITE BIRD CLINIC HEALTH AND WELFARE 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: WHITE BIRD CLINIC HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01First time form 5500 has been submittedYes
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

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1151102
Policy instance 3
Insurance contract or identification number1151102
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $3,052
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $48,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,052
Amount paid for insurance broker fees0
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR131
Policy instance 2
Insurance contract or identification numberOR131
Number of Individuals Covered46
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,090
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?No
Commission paid to Insurance BrokerUSD $1,090
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0039913
Policy instance 1
Insurance contract or identification numberG0039913
Number of Individuals Covered138
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $40,902
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,366,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,902
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0039913
Policy instance 1
Insurance contract or identification numberG0039913
Number of Individuals Covered127
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $40,214
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,254,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,214
Amount paid for insurance broker fees0
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR131
Policy instance 3
Insurance contract or identification numberOR131
Number of Individuals Covered84
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $969
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 $969
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5998211
Policy instance 2
Insurance contract or identification number5998211
Number of Individuals Covered100
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,572
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $51,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,572
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5998211
Policy instance 2
Insurance contract or identification number5998211
Number of Individuals Covered84
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,313
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,313
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0039913
Policy instance 1
Insurance contract or identification numberG0039913
Number of Individuals Covered119
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $28,801
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $979,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,801
Amount paid for insurance broker fees0
Insurance broker organization code?3
RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number15170344
Policy instance 4
Insurance contract or identification number15170344
Number of Individuals Covered185
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
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 $5,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR131
Policy instance 3
Insurance contract or identification numberOR131
Number of Individuals Covered58
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $710
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 $710
Amount paid for insurance broker fees0
Insurance broker organization code?3

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