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VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameVAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN
Plan identification number 502

VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

VAN DE POL ENTERPRISES has sponsored the creation of one or more 401k plans.

Company Name:VAN DE POL ENTERPRISES
Employer identification number (EIN):942428381
NAIC Classification:324110
NAIC Description:Petroleum Refineries

Additional information about VAN DE POL ENTERPRISES

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 1977-07-01
Company Identification Number: C0819422
Legal Registered Office Address: 5602 Pintail Ct

Stockton
United States of America (USA)
95207

More information about VAN DE POL ENTERPRISES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01LYDIA MACAHILAS2023-09-27
5022021-01-01LYDIA MACAHILAS2022-09-19
5022021-01-01LYDIA MACAHILAS2023-09-27
5022020-01-01LYDIA MACAHILAS2021-09-17
5022019-01-01LYDIA MACAHILAS2020-05-07
5022019-01-01LYDIA MACAHILAS2023-09-27
5022018-01-01LYDIA MACAHILAS2019-10-08
5022017-01-01
5022016-01-01JORDAN SHIELDS
5022016-01-01LYDIA MACAHILAS2018-11-27
5022015-06-01JORDAN SHIELDS
5022014-06-01JORDAN SHIELDS
5022013-06-01JORDAN SHIELDS
5022012-06-01JORDAN SHIELDS

Plan Statistics for VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN

401k plan membership statisitcs for VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN

Measure Date Value
2022: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01392
Total number of active participants reported on line 7a of the Form 55002022-01-01373
Number of retired or separated participants receiving benefits2022-01-014
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01377
Number of employers contributing to the scheme2022-01-010
2021: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01411
Total number of active participants reported on line 7a of the Form 55002021-01-01439
Number of retired or separated participants receiving benefits2021-01-016
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01445
Number of employers contributing to the scheme2021-01-010
2020: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01409
Total number of active participants reported on line 7a of the Form 55002020-01-01393
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 participants2020-01-01393
Number of employers contributing to the scheme2020-01-010
2019: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01395
Total number of active participants reported on line 7a of the Form 55002019-01-01409
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 participants2019-01-01409
Number of employers contributing to the scheme2019-01-010
2018: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01314
Total number of active participants reported on line 7a of the Form 55002018-01-01279
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 participants2018-01-01279
Number of employers contributing to the scheme2018-01-010
2017: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01314
Total number of active participants reported on line 7a of the Form 55002017-01-01388
Number of retired or separated participants receiving benefits2017-01-011
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01389
2016: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01294
Total number of active participants reported on line 7a of the Form 55002016-01-01323
Number of retired or separated participants receiving benefits2016-01-013
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01326
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2016-01-010
Total participants2016-01-01326
Number of participants with account balances2016-01-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2016-01-010
2015: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01257
Total number of active participants reported on line 7a of the Form 55002015-06-01293
Number of retired or separated participants receiving benefits2015-06-011
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01294
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-06-010
Total participants2015-06-01294
Number of participants with account balances2015-06-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2015-06-010
2014: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01209
Total number of active participants reported on line 7a of the Form 55002014-06-01255
Number of retired or separated participants receiving benefits2014-06-012
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-01257
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-06-010
Total participants2014-06-01257
Number of participants with account balances2014-06-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2014-06-010
2013: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01184
Total number of active participants reported on line 7a of the Form 55002013-06-01206
Number of retired or separated participants receiving benefits2013-06-013
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01209
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-06-010
Total participants2013-06-01209
Number of participants with account balances2013-06-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2013-06-010
2012: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-06-01184
Total number of active participants reported on line 7a of the Form 55002012-06-01184
Number of retired or separated participants receiving benefits2012-06-010
Number of other retired or separated participants entitled to future benefits2012-06-010
Total of all active and inactive participants2012-06-01184
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-06-010
Total participants2012-06-01184
Number of participants with account balances2012-06-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2012-06-010

Form 5500 Responses for VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN

2022: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedYes
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: VAN DE POL ENTERPRISES HEALTH AND WELFARE 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: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
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: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
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: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
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
2016: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes
2014: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan funding arrangement – General assets of the sponsorYes
2014-06-01Plan benefit arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – General assets of the sponsorYes
2013: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan funding arrangement – General assets of the sponsorYes
2013-06-01Plan benefit arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – General assets of the sponsorYes
2012: VAN DE POL ENTERPRISES HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01First time form 5500 has been submittedYes
2012-06-01Submission has been amendedNo
2012-06-01This submission is the final filingNo
2012-06-01This return/report is a short plan year return/report (less than 12 months)No
2012-06-01Plan is a collectively bargained planNo
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 4
Insurance contract or identification number10104898
Number of Individuals Covered445
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $22,889
Total amount of fees paid to insurance companyUSD $1,435
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $156,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,889
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number925854
Policy instance 3
Insurance contract or identification number925854
Number of Individuals Covered901
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $152,462
Total amount of fees paid to insurance companyUSD $1,653
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,048,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $152,462
Amount paid for insurance broker fees1653
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062369
Policy instance 2
Insurance contract or identification numberE5062369
Number of Individuals Covered194
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $28,625
Total amount of fees paid to insurance companyUSD $22,784
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $110,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,554
Amount paid for insurance broker fees11320
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered31
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,519
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $10,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,519
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062369
Policy instance 2
Insurance contract or identification numberE5062369
Number of Individuals Covered64
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $8,413
Total amount of fees paid to insurance companyUSD $965
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $51,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,962
Amount paid for insurance broker fees94
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberL01263
Policy instance 3
Insurance contract or identification numberL01263
Number of Individuals Covered792
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $165,950
Total amount of fees paid to insurance companyUSD $20,773
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,223,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $165,950
Amount paid for insurance broker fees14905
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062377
Policy instance 4
Insurance contract or identification numberE5062377
Number of Individuals Covered47
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,032
Total amount of fees paid to insurance companyUSD $741
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $41,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,594
Amount paid for insurance broker fees36
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062385
Policy instance 5
Insurance contract or identification numberE5062385
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $83
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $62
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 6
Insurance contract or identification number10104898
Number of Individuals Covered437
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $19,847
Total amount of fees paid to insurance companyUSD $2,451
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $135,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,847
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered60
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,719
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $18,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,719
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 7
Insurance contract or identification number10104898
Number of Individuals Covered393
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $21,697
Total amount of fees paid to insurance companyUSD $6,628
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $148,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,697
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062377
Policy instance 6
Insurance contract or identification numberE5062377
Number of Individuals Covered53
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,190
Total amount of fees paid to insurance companyUSD $634
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $40,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,245
Amount paid for insurance broker fees4
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062369
Policy instance 5
Insurance contract or identification numberE5062369
Number of Individuals Covered59
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,650
Total amount of fees paid to insurance companyUSD $605
Other welfare benefits providedACCIDENT, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $47,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,430
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract numberQ38-37674
Policy instance 4
Insurance contract or identification numberQ38-37674
Number of Individuals Covered326
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $35,771
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $362,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,771
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0065555
Policy instance 3
Insurance contract or identification numberW0065555
Number of Individuals Covered603
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,421
Total amount of fees paid to insurance companyUSD $130,839
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,379,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,421
Amount paid for insurance broker fees130839
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062385
Policy instance 2
Insurance contract or identification numberE5062385
Number of Individuals Covered1
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $93
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered393
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,148
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $20,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,148
Amount paid for insurance broker fees0
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract numberQ38-37674
Policy instance 4
Insurance contract or identification numberQ38-37674
Number of Individuals Covered346
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $33,554
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $335,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,554
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered68
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,936
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $26,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,936
Amount paid for insurance broker fees0
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062385
Policy instance 2
Insurance contract or identification numberE5062385
Number of Individuals Covered1
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $213
Total amount of fees paid to insurance companyUSD $122
Other welfare benefits providedACCIDENT, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0065555
Policy instance 3
Insurance contract or identification numberW0065555
Number of Individuals Covered611
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,787
Total amount of fees paid to insurance companyUSD $149,544
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,050,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,787
Amount paid for insurance broker fees149544
Additional information about fees paid to insurance brokerPRODUCER SERVICES FEES NON-MONETARY COMPENSATION
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 7
Insurance contract or identification number10104898
Number of Individuals Covered420
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $16,587
Total amount of fees paid to insurance companyUSD $5,557
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $113,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,496
Amount paid for insurance broker fees3897
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE5062377
Policy instance 6
Insurance contract or identification numberE5062377
Number of Individuals Covered53
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $18,263
Total amount of fees paid to insurance companyUSD $10,916
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $53,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,961
Amount paid for insurance broker fees235
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE506369
Policy instance 5
Insurance contract or identification numberE506369
Number of Individuals Covered63
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $20,725
Total amount of fees paid to insurance companyUSD $11,664
Other welfare benefits providedACCIDENT, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $59,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,838
Amount paid for insurance broker fees277
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE506369
Policy instance 5
Insurance contract or identification numberE506369
Number of Individuals Covered69
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,858
Total amount of fees paid to insurance companyUSD $4,332
Health Insurance Welfare BenefitNo
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
Other welfare benefits providedACCIDENT, CANCER, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $9,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $881
Amount paid for insurance broker fees1216
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered81
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,147
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $34,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,147
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW006555
Policy instance 2
Insurance contract or identification numberW006555
Number of Individuals Covered536
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $96,655
Total amount of fees paid to insurance companyUSD $28,050
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,877,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $96,655
Amount paid for insurance broker fees28050
Additional information about fees paid to insurance brokerBONUS OVERRIDE
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract numberQ38-37674
Policy instance 3
Insurance contract or identification numberQ38-37674
Number of Individuals Covered741
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $32,196
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $321,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,196
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 4
Insurance contract or identification number10104898
Number of Individuals Covered395
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $17,784
Total amount of fees paid to insurance companyUSD $3,556
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $121,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,784
Amount paid for insurance broker fees3556
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10104898
Policy instance 4
Insurance contract or identification number10104898
Number of Individuals Covered349
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,358
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $18,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,760
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number91996
Policy instance 3
Insurance contract or identification number91996
Number of Individuals Covered41
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $9,593
Total amount of fees paid to insurance companyUSD $0
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 providedACCIDENT,CANCER,HEART,STROKE
Welfare Benefit Premiums Paid to CarrierUSD $55,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,220
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NORTHWEST
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910525
Policy instance 2
Insurance contract or identification number910525
Number of Individuals Covered720
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $190,965
Total amount of fees paid to insurance companyUSD $15,727
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,166,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $129,830
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number29498
Policy instance 1
Insurance contract or identification number29498
Number of Individuals Covered115
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $7,311
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,780
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NORTHWEST

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