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TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan NameTYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN
Plan identification number 501

TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

TYREE OIL, INC. has sponsored the creation of one or more 401k plans.

Company Name:TYREE OIL, INC.
Employer identification number (EIN):930985141
NAIC Classification:447100
NAIC Description: Gasoline Stations, Gas

Additional information about TYREE OIL, INC.

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division
Incorporation Date: 1988-08-10
Company Identification Number: 12587887
Legal Registered Office Address: 800 WILLAMETTE ST STE 800

EUGENE
United States of America (USA)
97401

More information about TYREE OIL, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01EARLINE RUST2023-06-08
5012021-01-01EARLINE RUST2022-07-13
5012020-01-01KATIE HORNE2021-07-14
5012019-01-01JODY JOBANEK-SUITER2020-10-02
5012018-01-01
5012018-01-01JODY JOBANEK-SUITER2020-10-08
5012017-01-01

Plan Statistics for TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2022: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01160
Total number of active participants reported on line 7a of the Form 55002022-01-01176
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 participants2022-01-01176
Number of employers contributing to the scheme2022-01-010
2021: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01126
Total number of active participants reported on line 7a of the Form 55002021-01-01159
Number of retired or separated participants receiving benefits2021-01-011
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01160
Number of employers contributing to the scheme2021-01-010
2020: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01120
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
2019: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01115
Total number of active participants reported on line 7a of the Form 55002019-01-01119
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01119
Number of employers contributing to the scheme2019-01-010
2018: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01112
Total number of active participants reported on line 7a of the Form 55002018-01-01115
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01115
Number of employers contributing to the scheme2018-01-010
2017: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01109
Total number of active participants reported on line 7a of the Form 55002017-01-01112
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01112

Form 5500 Responses for TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN

2022: TYREE OIL, INC. HEALTH & WELFARE BENEFIT 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: TYREE OIL, INC. HEALTH & WELFARE BENEFIT 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: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: TYREE OIL, INC. HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 5
Insurance contract or identification number00
Number of Individuals Covered176
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 $4,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 4
Insurance contract or identification numberOR300216
Number of Individuals Covered125
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $733
Total amount of fees paid to insurance companyUSD $514
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $733
Amount paid for insurance broker fees514
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR384
Policy instance 3
Insurance contract or identification numberOR384
Number of Individuals Covered134
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,614
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 $2,614
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number28146
Policy instance 2
Insurance contract or identification number28146
Number of Individuals Covered176
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $9,112
Total amount of fees paid to insurance companyUSD $1,358
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $89,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,112
Amount paid for insurance broker fees1358
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number118595
Policy instance 1
Insurance contract or identification number118595
Number of Individuals Covered246
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,637
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,253,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,637
Amount paid for insurance broker fees0
Insurance broker organization code?3
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number118595
Policy instance 1
Insurance contract or identification number118595
Number of Individuals Covered217
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $37,317
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,268,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,317
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 number5966940
Policy instance 2
Insurance contract or identification number5966940
Number of Individuals Covered176
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,410
Total amount of fees paid to insurance companyUSD $2,480
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,752
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,410
Amount paid for insurance broker fees2480
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR384
Policy instance 3
Insurance contract or identification numberOR384
Number of Individuals Covered96
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,907
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,907
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 4
Insurance contract or identification numberOR300216
Number of Individuals Covered107
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $604
Total amount of fees paid to insurance companyUSD $514
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $604
Amount paid for insurance broker fees514
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 5
Insurance contract or identification number00
Number of Individuals Covered159
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 $4,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10247280
Policy instance 6
Insurance contract or identification number10247280
Number of Individuals Covered159
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,576
Total amount of fees paid to insurance companyUSD $469
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $30,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,576
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10247280
Policy instance 6
Insurance contract or identification number10247280
Number of Individuals Covered140
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,438
Total amount of fees paid to insurance companyUSD $816
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $24,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,438
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 5
Insurance contract or identification number00
Number of Individuals Covered126
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 $3,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 4
Insurance contract or identification numberOR300216
Number of Individuals Covered95
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $544
Total amount of fees paid to insurance companyUSD $402
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $544
Amount paid for insurance broker fees402
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR384
Policy instance 3
Insurance contract or identification numberOR384
Number of Individuals Covered95
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,754
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,754
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 number5966940
Policy instance 2
Insurance contract or identification number5966940
Number of Individuals Covered170
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,127
Total amount of fees paid to insurance companyUSD $496
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,127
Amount paid for insurance broker fees496
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number118595
Policy instance 1
Insurance contract or identification number118595
Number of Individuals Covered186
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $30,893
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,045,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,893
Amount paid for insurance broker fees0
Insurance broker organization code?3
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number118595
Policy instance 1
Insurance contract or identification number118595
Number of Individuals Covered168
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $23,305
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $851,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,305
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 numberG0035679
Policy instance 2
Insurance contract or identification numberG0035679
Number of Individuals Covered114
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,288
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,288
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 numberOR384
Policy instance 3
Insurance contract or identification numberOR384
Number of Individuals Covered73
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,378
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,378
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 4
Insurance contract or identification numberOR300216
Number of Individuals Covered83
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $481
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $481
Amount paid for insurance broker fees0
Insurance broker organization code?3
CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 5
Insurance contract or identification number00
Number of Individuals Covered119
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
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 $3,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10247280
Policy instance 6
Insurance contract or identification number10247280
Number of Individuals Covered119
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,374
Total amount of fees paid to insurance companyUSD $989
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $22,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,374
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number15064182
Policy instance 4
Insurance contract or identification number15064182
Number of Individuals Covered130
Insurance policy start date2018-03-01
Insurance policy end date2018-12-31
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 $1,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number15064182
Policy instance 3
Insurance contract or identification number15064182
Number of Individuals Covered130
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
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 $1,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0035679
Policy instance 2
Insurance contract or identification numberG0035679
Number of Individuals Covered152
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $32,772
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,061,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,772
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 1
Insurance contract or identification numberOR300216
Number of Individuals Covered111
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $783
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $12,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $783
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 number15064182
Policy instance 3
Insurance contract or identification number15064182
Number of Individuals Covered130
Insurance policy start date2016-03-01
Insurance policy end date2017-02-28
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 $2,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0035679
Policy instance 2
Insurance contract or identification numberG0035679
Number of Individuals Covered165
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $35,065
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,155,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,065
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR300216
Policy instance 1
Insurance contract or identification numberOR300216
Number of Individuals Covered124
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $873
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $14,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $873
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY

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