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EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 401k Plan overview

Plan NameEMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC.
Plan identification number 501

EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Other welfare benefit cover

401k Sponsoring company profile

ELEPHANTS FOOD GROUP INC. has sponsored the creation of one or more 401k plans.

Company Name:ELEPHANTS FOOD GROUP INC.
Employer identification number (EIN):930734229
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-07-01
5012021-07-01
5012020-07-01
5012019-07-01
5012018-07-01
5012017-07-01EVELYN VALLIN
5012015-02-01LYDIA GARCIA
5012014-02-01STEVE WEINBERG
5012013-02-01STEVE WEINBERG
5012012-02-01STEVE WEINBERG
5012011-02-01STEVE WEINBERG
5012010-02-01STEVE WEINBERG
5012009-02-01STEVE WEINBERG
5012008-02-01STEVE WEINBERG
5012007-02-01STEVE WEINBERG

Plan Statistics for EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC.

401k plan membership statisitcs for EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC.

Measure Date Value
2022: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2022 401k membership
Total participants, beginning-of-year2022-07-01141
Total number of active participants reported on line 7a of the Form 55002022-07-01154
Number of retired or separated participants receiving benefits2022-07-011
Number of other retired or separated participants entitled to future benefits2022-07-010
Total of all active and inactive participants2022-07-01155
2021: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2021 401k membership
Total participants, beginning-of-year2021-07-01157
Total number of active participants reported on line 7a of the Form 55002021-07-01141
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01141
2020: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2020 401k membership
Total participants, beginning-of-year2020-07-01170
Total number of active participants reported on line 7a of the Form 55002020-07-01157
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01157
2019: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2019 401k membership
Total participants, beginning-of-year2019-07-01235
Total number of active participants reported on line 7a of the Form 55002019-07-01170
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01170
2018: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2018 401k membership
Total participants, beginning-of-year2018-07-01235
Total number of active participants reported on line 7a of the Form 55002018-07-01246
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01246
2017: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2017 401k membership
Total participants, beginning-of-year2017-07-01192
Total number of active participants reported on line 7a of the Form 55002017-07-01235
Total of all active and inactive participants2017-07-01235
2015: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2015 401k membership
Total participants, beginning-of-year2015-02-01245
Total number of active participants reported on line 7a of the Form 55002015-02-01203
Total of all active and inactive participants2015-02-01203
2014: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2014 401k membership
Total participants, beginning-of-year2014-02-01132
Total number of active participants reported on line 7a of the Form 55002014-02-01245
Total of all active and inactive participants2014-02-01245
2013: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2013 401k membership
Total participants, beginning-of-year2013-02-01104
Total number of active participants reported on line 7a of the Form 55002013-02-01132
Total of all active and inactive participants2013-02-01132
2012: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2012 401k membership
Total participants, beginning-of-year2012-02-01106
Total number of active participants reported on line 7a of the Form 55002012-02-01104
Total of all active and inactive participants2012-02-01104
2011: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2011 401k membership
Total participants, beginning-of-year2011-02-01111
Total number of active participants reported on line 7a of the Form 55002011-02-01106
Total of all active and inactive participants2011-02-01106
2010: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2010 401k membership
Total participants, beginning-of-year2010-02-01117
Total number of active participants reported on line 7a of the Form 55002010-02-01111
Total of all active and inactive participants2010-02-01111
2009: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2009 401k membership
Total participants, beginning-of-year2009-02-01127
Total number of active participants reported on line 7a of the Form 55002009-02-01117
Total of all active and inactive participants2009-02-01117
2008: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2008 401k membership
Total participants, beginning-of-year2008-02-01127
Total number of active participants reported on line 7a of the Form 55002008-02-01127
Total of all active and inactive participants2008-02-01127
2007: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2007 401k membership
Total participants, beginning-of-year2007-02-01100
Total number of active participants reported on line 7a of the Form 55002007-02-01127
Total of all active and inactive participants2007-02-01127

Form 5500 Responses for EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC.

2022: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Submission has been amendedNo
2022-07-01This submission is the final filingNo
2022-07-01This return/report is a short plan year return/report (less than 12 months)No
2022-07-01Plan is a collectively bargained planNo
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan funding arrangement – General assets of the sponsorYes
2022-07-01Plan benefit arrangement – InsuranceYes
2022-07-01Plan benefit arrangement – General assets of the sponsorYes
2021: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Submission has been amendedNo
2018-07-01This submission is the final filingNo
2018-07-01This return/report is a short plan year return/report (less than 12 months)No
2018-07-01Plan is a collectively bargained planNo
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – InsuranceYes
2017: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Submission has been amendedNo
2017-07-01This submission is the final filingNo
2017-07-01This return/report is a short plan year return/report (less than 12 months)No
2017-07-01Plan is a collectively bargained planNo
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2015: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan benefit arrangement – InsuranceYes
2014: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – InsuranceYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedYes
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedNo
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)No
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – InsuranceYes
2008: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2008 form 5500 responses
2008-02-01Type of plan entitySingle employer plan
2008-02-01Submission has been amendedNo
2008-02-01This submission is the final filingNo
2008-02-01This return/report is a short plan year return/report (less than 12 months)No
2008-02-01Plan is a collectively bargained planNo
2008-02-01Plan funding arrangement – InsuranceYes
2008-02-01Plan benefit arrangement – InsuranceYes
2007: EMPLOYEE BENEFIT PLAN FOR ELEPHANTS FOOD GROUP, INC. 2007 form 5500 responses
2007-02-01Type of plan entitySingle employer plan
2007-02-01First time form 5500 has been submittedYes
2007-02-01Submission has been amendedNo
2007-02-01This submission is the final filingNo
2007-02-01This return/report is a short plan year return/report (less than 12 months)No
2007-02-01Plan is a collectively bargained planNo
2007-02-01Plan funding arrangement – InsuranceYes
2007-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number885034G
Policy instance 2
Insurance contract or identification number885034G
Number of Individuals Covered51
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $1,813
Total amount of fees paid to insurance companyUSD $546
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 $19,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,813
Insurance broker organization code?3
Amount paid for insurance broker fees546
Additional information about fees paid to insurance brokerBONUS
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered185
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $10,930
Total amount of fees paid to insurance companyUSD $772
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $390,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,930
Amount paid for insurance broker fees772
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number885034G
Policy instance 2
Insurance contract or identification number885034G
Number of Individuals Covered30
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $1,399
Total amount of fees paid to insurance companyUSD $1,105
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 $12,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,399
Insurance broker organization code?3
Amount paid for insurance broker fees1105
Additional information about fees paid to insurance brokerBONUS
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered160
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $18,657
Total amount of fees paid to insurance companyUSD $3,149
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $612,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,657
Amount paid for insurance broker fees3149
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number885034G
Policy instance 2
Insurance contract or identification number885034G
Number of Individuals Covered62
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $1,282
Total amount of fees paid to insurance companyUSD $685
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 $12,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,282
Insurance broker organization code?3
Amount paid for insurance broker fees685
Additional information about fees paid to insurance brokerBONUS
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered157
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $20,541
Total amount of fees paid to insurance companyUSD $757
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $670,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,541
Amount paid for insurance broker fees757
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number885034G
Policy instance 2
Insurance contract or identification number885034G
Number of Individuals Covered156
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $1,500
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 $15,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,500
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered170
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $26,620
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $989,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,620
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number885034
Policy instance 2
Insurance contract or identification number885034
Number of Individuals Covered416
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $1,576
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE AND AD&D
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 $15,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,576
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered246
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $21,726
Total amount of fees paid to insurance companyUSD $983
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $853,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,726
Amount paid for insurance broker fees983
Additional information about fees paid to insurance brokerFEES AND OTHER COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered325
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $25,638
Total amount of fees paid to insurance companyUSD $1,019
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
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 $786,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,638
Amount paid for insurance broker fees1019
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 3
Insurance contract or identification number135469
Number of Individuals Covered20
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $712
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $606
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF NY, INC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 2
Insurance contract or identification number135469
Number of Individuals Covered79
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $2,938
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,382
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF NY INC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 1
Insurance contract or identification number18808
Number of Individuals Covered203
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $19,248
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 BenefitYes
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
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 $707,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,343
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 3
Insurance contract or identification number135469
Number of Individuals Covered20
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $5
Total amount of fees paid to insurance companyUSD $133
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5
Amount paid for insurance broker fees133
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 2
Insurance contract or identification number135469
Number of Individuals Covered96
Insurance policy start date2015-02-01
Insurance policy end date2016-01-31
Total amount of commissions paid to insurance brokerUSD $1,295
Total amount of fees paid to insurance companyUSD $464
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 BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,295
Amount paid for insurance broker fees464
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 2
Insurance contract or identification number18808
Number of Individuals Covered129
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $15,111
Total amount of fees paid to insurance companyUSD $802
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 BenefitYes
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
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 $512,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,111
Amount paid for insurance broker fees802
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMONTGOMERY & GRAHAM, INC.
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered245
Insurance policy start date2014-02-01
Insurance policy end date2015-01-31
Total amount of commissions paid to insurance brokerUSD $2,695
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,695
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered132
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $2,133
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,133
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 2
Insurance contract or identification number18808
Number of Individuals Covered129
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $15,111
Total amount of fees paid to insurance companyUSD $802
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 BenefitYes
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
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 $512,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,111
Amount paid for insurance broker fees802
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMONTGOMERY & GRAHAM, INC.
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered104
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $1,724
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,724
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number18808
Policy instance 2
Insurance contract or identification number18808
Number of Individuals Covered107
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $9,613
Total amount of fees paid to insurance companyUSD $6,250
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 BenefitYes
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
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 $389,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,613
Amount paid for insurance broker fees6250
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameMONTGOMERY & GRAHAM, INC.
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered106
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $1,743
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered111
Insurance policy start date2010-02-01
Insurance policy end date2011-01-31
Total amount of commissions paid to insurance brokerUSD $1,732
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 BenefitYes
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
Commission paid to Insurance BrokerUSD $1,732
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered117
Insurance policy start date2009-02-01
Insurance policy end date2010-01-31
Total amount of commissions paid to insurance brokerUSD $1,689
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,689
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered127
Insurance policy start date2008-02-01
Insurance policy end date2009-01-31
Total amount of commissions paid to insurance brokerUSD $1,831
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,831
Insurance broker organization code?3
Insurance broker nameARAM M MAHSHIGIAN
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number135469
Policy instance 1
Insurance contract or identification number135469
Number of Individuals Covered127
Insurance policy start date2007-02-01
Insurance policy end date2008-01-31
Total amount of commissions paid to insurance brokerUSD $1,812
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,812
Insurance broker organization code?3
Insurance broker nameARAM MAHSHIGIAN

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