KIRBY NAGELHOUT CONSTRUCTION CO. has sponsored the creation of one or more 401k plans.
Additional information about KIRBY NAGELHOUT CONSTRUCTION CO.
Submission information for form 5500 for 401k plan KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN
401k plan membership statisitcs for KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-09-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 120 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 0 |
| Total of all active and inactive participants | 2022-09-01 | 120 |
| Number of employers contributing to the scheme | 2022-09-01 | 0 |
| 2021: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 138 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 138 |
| Number of employers contributing to the scheme | 2021-09-01 | 0 |
| 2020: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 125 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 125 |
| Number of employers contributing to the scheme | 2020-09-01 | 0 |
| 2019: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 115 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 115 |
| Number of employers contributing to the scheme | 2019-09-01 | 0 |
| 2018: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 110 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 110 |
| Number of employers contributing to the scheme | 2018-09-01 | 0 |
| 2017: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 115 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 115 |
| Number of employers contributing to the scheme | 2017-09-01 | 0 |
| 2009: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 233 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 233 |
| 2022: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: KIRBY NAGELHOUT CONSTRUCTION EMPLOYEE WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | Yes |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MEDICAL AIR SERVICES ASSOCIATION, INC. (National Association of Insurance Commissioners NAIC id number: 62191 ) |
| Policy contract number | B2BKNCC |
| Policy instance | 4 |
| Insurance contract or identification number | B2BKNCC | | Number of Individuals Covered | 53 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $1,442 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $733 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 3 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $3,536 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,138 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 2 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $12,848 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $173,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,848 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 119653 |
| Policy instance | 1 |
| Insurance contract or identification number | 119653 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $52,716 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,757,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,716 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 758553 |
| Policy instance | 2 |
| Insurance contract or identification number | 758553 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $5,316 | | Total amount of fees paid to insurance company | USD $471 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,316 | | Amount paid for insurance broker fees | 471 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $7,484 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $72,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,484 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 4 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $1,767 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $671 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MEDICAL AIR SERVICES ASSOCIATION, INC. (National Association of Insurance Commissioners NAIC id number: 62191 ) |
| Policy contract number | B2BKNCC |
| Policy instance | 5 |
| Insurance contract or identification number | B2BKNCC | | Number of Individuals Covered | 138 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 119653 |
| Policy instance | 1 |
| Insurance contract or identification number | 119653 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $50,010 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,539,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,010 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MEDICAL AIR SERVICES ASSOCIATION, INC. (National Association of Insurance Commissioners NAIC id number: 62191 ) |
| Policy contract number | B2BKNCC |
| Policy instance | 5 |
| Insurance contract or identification number | B2BKNCC | | Number of Individuals Covered | 125 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 4 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $2,256 | | Total amount of fees paid to insurance company | USD $24 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $16,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $676 | | Amount paid for insurance broker fees | 17 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $6,242 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $58,211 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,242 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 758553 |
| Policy instance | 2 |
| Insurance contract or identification number | 758553 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $4,716 | | Total amount of fees paid to insurance company | USD $1,148 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,545 | | Amount paid for insurance broker fees | 1148 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 119653 |
| Policy instance | 1 |
| Insurance contract or identification number | 119653 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $46,251 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,451,060 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,251 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MEDICAL AIR SERVICES ASSOCIATION, INC. (National Association of Insurance Commissioners NAIC id number: 62191 ) |
| Policy contract number | B2BKNCC |
| Policy instance | 5 |
| Insurance contract or identification number | B2BKNCC | | Number of Individuals Covered | 40 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $1,602 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,602 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 4 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $3,506 | | Total amount of fees paid to insurance company | USD $178 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $19,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,585 | | Amount paid for insurance broker fees | 149 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $6,659 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $62,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,659 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 758553 |
| Policy instance | 2 |
| Insurance contract or identification number | 758553 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $4,740 | | Total amount of fees paid to insurance company | USD $3,764 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,740 | | Amount paid for insurance broker fees | 3764 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0031972 |
| Policy instance | 1 |
| Insurance contract or identification number | G0031972 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $33,468 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,336,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,468 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001887 |
| Policy instance | 2 |
| Insurance contract or identification number | 10001887 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $3,602 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $110,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,270 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $4,965 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $42,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,965 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 4 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $1,854 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $15,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $548 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0031972 |
| Policy instance | 1 |
| Insurance contract or identification number | G0031972 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $36,636 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,287,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,636 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0031972 |
| Policy instance | 1 |
| Insurance contract or identification number | G0031972 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $30,096 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,170,910 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
| Policy contract number | 10001887 |
| Policy instance | 2 |
| Insurance contract or identification number | 10001887 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $2,921 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $107,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | FK055 |
| Policy instance | 4 |
| Insurance contract or identification number | FK055 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $2,438 | | Total amount of fees paid to insurance company | USD $163 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $18,957 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | OR300983 |
| Policy instance | 3 |
| Insurance contract or identification number | OR300983 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $5,468 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $46,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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