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SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameSMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN
Plan identification number 501

SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN Benefits

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

SMOTHERS & WHITE, INC. has sponsored the creation of one or more 401k plans.

Company Name:SMOTHERS & WHITE, INC.
Employer identification number (EIN):942835697
NAIC Classification:441110
NAIC Description:New Car Dealers

Additional information about SMOTHERS & WHITE, INC.

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 1982-07-21
Company Identification Number: C1117571
Legal Registered Office Address: 2881 Corby Ave

Santa Rosa
United States of America (USA)
95407

More information about SMOTHERS & WHITE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-03-01
5012019-03-01
5012018-03-01

Plan Statistics for SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01110
Total number of active participants reported on line 7a of the Form 55002022-03-01112
Total of all active and inactive participants2022-03-01112
2019: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01101
Total number of active participants reported on line 7a of the Form 55002019-03-0191
Total of all active and inactive participants2019-03-0191
2018: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01108
Total number of active participants reported on line 7a of the Form 55002018-03-01101
Total of all active and inactive participants2018-03-01101

Form 5500 Responses for SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN

2022: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)No
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – InsuranceYes
2019: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Submission has been amendedNo
2019-03-01This submission is the final filingNo
2019-03-01This return/report is a short plan year return/report (less than 12 months)No
2019-03-01Plan is a collectively bargained planNo
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – InsuranceYes
2018: SMOTHERS & WHITE INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01First time form 5500 has been submittedYes
2018-03-01Submission has been amendedNo
2018-03-01This submission is the final filingNo
2018-03-01This return/report is a short plan year return/report (less than 12 months)No
2018-03-01Plan is a collectively bargained planNo
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0C3F2
Policy instance 4
Insurance contract or identification numberGVTL0C3F2
Number of Individuals Covered52
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $783
Total amount of fees paid to insurance companyUSD $5,000
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $463
Insurance broker organization code?3
Amount paid for insurance broker fees5000
Additional information about fees paid to insurance brokerADMINISTRATION
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number113402
Policy instance 3
Insurance contract or identification number113402
Number of Individuals Covered16
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $5,179
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $129,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,179
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605172
Policy instance 2
Insurance contract or identification number605172
Number of Individuals Covered75
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $21,810
Total amount of fees paid to insurance companyUSD $17
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $466,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,810
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUCG0C3F2
Policy instance 1
Insurance contract or identification numberGLUCG0C3F2
Number of Individuals Covered112
Insurance policy start date2022-03-01
Insurance policy end date2023-02-28
Total amount of commissions paid to insurance brokerUSD $780
Total amount of fees paid to insurance companyUSD $5,000
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $451
Insurance broker organization code?3
Amount paid for insurance broker fees5000
Additional information about fees paid to insurance brokerADMINISTRATION
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number152376
Policy instance 1
Insurance contract or identification number152376
Number of Individuals Covered91
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $757
Total amount of fees paid to insurance companyUSD $245
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $757
Amount paid for insurance broker fees245
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
WESTERN HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number950190
Policy instance 6
Insurance contract or identification number950190
Number of Individuals Covered15
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $3,461
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $86,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,461
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605172
Policy instance 2
Insurance contract or identification number605172
Number of Individuals Covered72
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $17,733
Total amount of fees paid to insurance companyUSD $6
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $387,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,733
Amount paid for insurance broker fees6
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00102331
Policy instance 5
Insurance contract or identification number00102331
Number of Individuals Covered77
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $739
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $739
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1090303
Policy instance 3
Insurance contract or identification number1090303
Number of Individuals Covered134
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $7,005
Total amount of fees paid to insurance companyUSD $1,319
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $69,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,005
Amount paid for insurance broker fees1319
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number113402
Policy instance 4
Insurance contract or identification number113402
Number of Individuals Covered16
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $5,402
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $135,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,402
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number152376
Policy instance 1
Insurance contract or identification number152376
Number of Individuals Covered101
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $553
Total amount of fees paid to insurance companyUSD $274
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $553
Amount paid for insurance broker fees274
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
WESTERN HEALTH ADVANTAGE (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number950190
Policy instance 6
Insurance contract or identification number950190
Number of Individuals Covered19
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $3,899
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $106,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,899
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00102331
Policy instance 5
Insurance contract or identification number00102331
Number of Individuals Covered81
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $684
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $684
Insurance broker organization code?3
SUTTER HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15107 )
Policy contract number113402
Policy instance 4
Insurance contract or identification number113402
Number of Individuals Covered19
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $7,038
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $144,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,038
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605172
Policy instance 2
Insurance contract or identification number605172
Number of Individuals Covered67
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $16,056
Total amount of fees paid to insurance companyUSD $1,285
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $321,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,056
Amount paid for insurance broker fees1285
Additional information about fees paid to insurance brokerBONUS NON-MONETARY COMPENSATION
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1090303
Policy instance 3
Insurance contract or identification number1090303
Number of Individuals Covered84
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $6,545
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $65,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,545
Insurance broker organization code?3

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