401k Plan data: OAKS CARD CLUB HEALTH AND WELFARE PLAN plan

OAKS CARD CLUB HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	OAKS CARD CLUB HEALTH AND WELFARE PLAN
Plan identification number	502

OAKS CARD CLUB HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

OAKS CLUB ROOM has sponsored the creation of one or more 401k plans.

Company Name: OAKS CLUB ROOM

Employer identification number (EIN): 941194137

NAIC Classification: 713200
NAIC Description: Gambling Industries

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OAKS CARD CLUB HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2023-08-01 WARREN TAI 2024-12-11
502 2022-08-01 WARREN TAI 2024-02-14
502 2019-08-01 WARREN TAI 2021-01-19
502 2018-08-01 WARREN TAI 2020-02-21
502 2017-10-01
502 2016-10-01
502 2015-10-01 WARREN TAI
502 2014-10-01 LOUANNE WASSERMAN
502 2013-10-01 JOHN TIBBETTS LOUANNE WASSERMAN 2015-04-29
502 2012-10-01 JOHN TIBBETTS LOUANNE WASSERMAN 2014-02-25
502 2011-10-01 JOHN TIBBETTS LOUANNE WASSERMAN 2013-03-18
502 2009-10-01 LOUANNE WASSERMAN JOHN TIBBETTS 2011-01-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2023-08-01	WARREN TAI	2024-12-11
502	2022-08-01	WARREN TAI	2024-02-14
502	2019-08-01	WARREN TAI	2021-01-19
502	2018-08-01	WARREN TAI	2020-02-21
502	2017-10-01
502	2016-10-01
502	2015-10-01	WARREN TAI
502	2014-10-01	LOUANNE WASSERMAN
502	2013-10-01	JOHN TIBBETTS		LOUANNE WASSERMAN	2015-04-29
502	2012-10-01	JOHN TIBBETTS		LOUANNE WASSERMAN	2014-02-25
502	2011-10-01	JOHN TIBBETTS		LOUANNE WASSERMAN	2013-03-18
502	2009-10-01	LOUANNE WASSERMAN		JOHN TIBBETTS	2011-01-24

Form 5500 Responses for OAKS CARD CLUB HEALTH AND WELFARE PLAN

2023: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-08-01	Type of plan entity	Single employer plan
2023-08-01	Plan funding arrangement – Insurance	Yes
2023-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-08-01	Plan benefit arrangement – Insurance	Yes
2023-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-08-01	Type of plan entity	Single employer plan
2022-08-01	Plan funding arrangement – Insurance	Yes
2022-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-08-01	Plan benefit arrangement – Insurance	Yes
2022-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-08-01	Type of plan entity	Single employer plan
2019-08-01	Plan funding arrangement – Insurance	Yes
2019-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-08-01	Plan benefit arrangement – Insurance	Yes
2019-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Plan funding arrangement – Insurance	Yes
2018-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-10-01	Type of plan entity	Single employer plan
2017-10-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2017-10-01	Plan funding arrangement – Insurance	Yes
2017-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-10-01	Plan benefit arrangement – Insurance	Yes
2017-10-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-10-01	Type of plan entity	Single employer plan
2016-10-01	Submission has been amended	No
2016-10-01	This submission is the final filing	No
2016-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-10-01	Plan is a collectively bargained plan	No
2016-10-01	Plan funding arrangement – Insurance	Yes
2016-10-01	Plan benefit arrangement – Insurance	Yes
2015: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-10-01	Type of plan entity	Single employer plan
2015-10-01	Submission has been amended	No
2015-10-01	This submission is the final filing	No
2015-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-10-01	Plan is a collectively bargained plan	No
2015-10-01	Plan funding arrangement – Insurance	Yes
2015-10-01	Plan benefit arrangement – Insurance	Yes
2014: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Submission has been amended	No
2014-10-01	This submission is the final filing	No
2014-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-10-01	Plan is a collectively bargained plan	No
2014-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2013: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-10-01	Type of plan entity	Single employer plan
2013-10-01	Submission has been amended	No
2013-10-01	This submission is the final filing	No
2013-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-10-01	Plan is a collectively bargained plan	No
2013-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-10-01	Plan benefit arrangement – Insurance	Yes
2012: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Submission has been amended	No
2012-10-01	This submission is the final filing	No
2012-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-10-01	Plan is a collectively bargained plan	No
2012-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	Submission has been amended	No
2011-10-01	This submission is the final filing	No
2011-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-10-01	Plan is a collectively bargained plan	No
2011-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes
2009: OAKS CARD CLUB HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-10-01	Type of plan entity	Single employer plan
2009-10-01	Submission has been amended	No
2009-10-01	This submission is the final filing	No
2009-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-10-01	Plan is a collectively bargained plan	No
2009-10-01	Plan funding arrangement – Insurance	Yes
2009-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

Insurance contract or identification number	2969
Number of Individuals Covered	119
Insurance policy start date	2023-08-01
Insurance policy end date	2024-07-31
Total amount of commissions paid to insurance broker	USD $6,284
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $72,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

G0358A

Policy instance

Insurance contract or identification number	G0358A
Number of Individuals Covered	36
Insurance policy start date	2023-08-01
Insurance policy end date	2024-07-31
Total amount of commissions paid to insurance broker	USD $20,273
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $506,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

Insurance contract or identification number	36036
Number of Individuals Covered	71
Insurance policy start date	2023-08-01
Insurance policy end date	2024-07-31
Total amount of commissions paid to insurance broker	USD $31,751
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $618,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

G0358A

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

G0358A

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

G0358A

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

G0358A

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

75795

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

76385A

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

75795/2969

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

76385/62747

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

75795

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

76385/62747

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

75795

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

75795

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

76385/62747

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

40591/62747

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

05795

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

2969

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

36036

Policy instance

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

05795

Policy instance

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 95567 )

Policy contract number

40591/62747

Policy instance

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Company Name:	OAKS CLUB ROOM
Employer identification number (EIN):	941194137
NAIC Classification:	713200
NAIC Description:	Gambling Industries