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PREMIUM PLAN ONLY 401k Plan overview

Plan NamePREMIUM PLAN ONLY
Plan identification number 501

PREMIUM PLAN ONLY Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Vision

401k Sponsoring company profile

GATEWAY LANDSCAPE CONSTRUCTION, INC. has sponsored the creation of one or more 401k plans.

Company Name:GATEWAY LANDSCAPE CONSTRUCTION, INC.
Employer identification number (EIN):942938778
NAIC Classification:238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PREMIUM PLAN ONLY

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01
5012021-02-01
5012020-02-01
5012019-02-01
5012018-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2019-07-22
5012017-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2018-08-30
5012016-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2017-07-14
5012015-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2016-07-19
5012014-02-01ELIZABETH SANTIAGO
5012013-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2014-04-08
5012012-02-01ELIZABETH SANTIAGO ELIZABETH SANTIAGO2013-04-15
5012011-02-01ELIZABETH SANTIAGO
5012010-02-01WENDY S LEWIS
5012009-02-01WENDY LEWIS

Plan Statistics for PREMIUM PLAN ONLY

401k plan membership statisitcs for PREMIUM PLAN ONLY

Measure Date Value
2022: PREMIUM PLAN ONLY 2022 401k membership
Total participants, beginning-of-year2022-02-0117
Total number of active participants reported on line 7a of the Form 55002022-02-013
Total of all active and inactive participants2022-02-013
Total participants2022-02-013
2021: PREMIUM PLAN ONLY 2021 401k membership
Total participants, beginning-of-year2021-02-0116
Total number of active participants reported on line 7a of the Form 55002021-02-013
Total of all active and inactive participants2021-02-013
Total participants2021-02-013
2020: PREMIUM PLAN ONLY 2020 401k membership
Total participants, beginning-of-year2020-02-0116
Total number of active participants reported on line 7a of the Form 55002020-02-012
Total of all active and inactive participants2020-02-012
Total participants2020-02-012
2019: PREMIUM PLAN ONLY 2019 401k membership
Total participants, beginning-of-year2019-02-0116
Total number of active participants reported on line 7a of the Form 55002019-02-012
Total of all active and inactive participants2019-02-012
Total participants2019-02-012
2018: PREMIUM PLAN ONLY 2018 401k membership
Total participants, beginning-of-year2018-02-0116
Total number of active participants reported on line 7a of the Form 55002018-02-012
Number of retired or separated participants receiving benefits2018-02-010
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-012
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2018-02-010
Total participants2018-02-012
2017: PREMIUM PLAN ONLY 2017 401k membership
Total participants, beginning-of-year2017-02-0117
Total number of active participants reported on line 7a of the Form 55002017-02-013
Number of retired or separated participants receiving benefits2017-02-010
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-013
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2017-02-010
Total participants2017-02-013
2016: PREMIUM PLAN ONLY 2016 401k membership
Total participants, beginning-of-year2016-02-0120
Total number of active participants reported on line 7a of the Form 55002016-02-013
Number of retired or separated participants receiving benefits2016-02-010
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-013
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2016-02-010
Total participants2016-02-013
2015: PREMIUM PLAN ONLY 2015 401k membership
Total participants, beginning-of-year2015-02-0116
Total number of active participants reported on line 7a of the Form 55002015-02-014
Number of retired or separated participants receiving benefits2015-02-010
Number of other retired or separated participants entitled to future benefits2015-02-010
Total of all active and inactive participants2015-02-014
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-02-010
Total participants2015-02-014
2014: PREMIUM PLAN ONLY 2014 401k membership
Total participants, beginning-of-year2014-02-0115
Total number of active participants reported on line 7a of the Form 55002014-02-015
Number of retired or separated participants receiving benefits2014-02-010
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-015
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-02-010
Total participants2014-02-015
2013: PREMIUM PLAN ONLY 2013 401k membership
Total participants, beginning-of-year2013-02-0115
Total number of active participants reported on line 7a of the Form 55002013-02-019
Number of retired or separated participants receiving benefits2013-02-010
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-019
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-02-010
Total participants2013-02-019
2012: PREMIUM PLAN ONLY 2012 401k membership
Total participants, beginning-of-year2012-02-0116
Total number of active participants reported on line 7a of the Form 55002012-02-018
Number of retired or separated participants receiving benefits2012-02-010
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-018
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-02-010
Total participants2012-02-018
2011: PREMIUM PLAN ONLY 2011 401k membership
Total participants, beginning-of-year2011-02-0116
Total number of active participants reported on line 7a of the Form 55002011-02-019
Total of all active and inactive participants2011-02-019
Total participants2011-02-019
2010: PREMIUM PLAN ONLY 2010 401k membership
Total participants, beginning-of-year2010-02-0118
Total number of active participants reported on line 7a of the Form 55002010-02-0110
Total of all active and inactive participants2010-02-0110
Total participants2010-02-0110
2009: PREMIUM PLAN ONLY 2009 401k membership
Total participants, beginning-of-year2009-02-0119
Total number of active participants reported on line 7a of the Form 55002009-02-0111
Total of all active and inactive participants2009-02-0111
Total participants2009-02-0111

Form 5500 Responses for PREMIUM PLAN ONLY

2022: PREMIUM PLAN ONLY 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – General assets of the sponsorYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: PREMIUM PLAN ONLY 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Submission has been amendedNo
2021-02-01This submission is the final filingNo
2021-02-01This return/report is a short plan year return/report (less than 12 months)No
2021-02-01Plan is a collectively bargained planNo
2021-02-01Plan funding arrangement – General assets of the sponsorYes
2021-02-01Plan benefit arrangement – InsuranceYes
2020: PREMIUM PLAN ONLY 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedNo
2020-02-01This submission is the final filingNo
2020-02-01This return/report is a short plan year return/report (less than 12 months)No
2020-02-01Plan is a collectively bargained planNo
2020-02-01Plan funding arrangement – General assets of the sponsorYes
2020-02-01Plan benefit arrangement – InsuranceYes
2019: PREMIUM PLAN ONLY 2019 form 5500 responses
2019-02-01Type of plan entitySingle employer plan
2019-02-01Submission has been amendedNo
2019-02-01This submission is the final filingNo
2019-02-01This return/report is a short plan year return/report (less than 12 months)No
2019-02-01Plan is a collectively bargained planNo
2019-02-01Plan funding arrangement – General assets of the sponsorYes
2019-02-01Plan benefit arrangement – InsuranceYes
2018: PREMIUM PLAN ONLY 2018 form 5500 responses
2018-02-01Type of plan entitySingle employer plan
2018-02-01Submission has been amendedNo
2018-02-01This submission is the final filingNo
2018-02-01This return/report is a short plan year return/report (less than 12 months)No
2018-02-01Plan is a collectively bargained planNo
2018-02-01Plan funding arrangement – General assets of the sponsorYes
2018-02-01Plan benefit arrangement – InsuranceYes
2017: PREMIUM PLAN ONLY 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Submission has been amendedNo
2017-02-01This submission is the final filingNo
2017-02-01This return/report is a short plan year return/report (less than 12 months)No
2017-02-01Plan is a collectively bargained planNo
2017-02-01Plan funding arrangement – General assets of the sponsorYes
2017-02-01Plan benefit arrangement – InsuranceYes
2016: PREMIUM PLAN ONLY 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – General assets of the sponsorYes
2016-02-01Plan benefit arrangement – InsuranceYes
2015: PREMIUM PLAN ONLY 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – General assets of the sponsorYes
2015-02-01Plan benefit arrangement – InsuranceYes
2014: PREMIUM PLAN ONLY 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – General assets of the sponsorYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: PREMIUM PLAN ONLY 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – General assets of the sponsorYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: PREMIUM PLAN ONLY 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – General assets of the sponsorYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: PREMIUM PLAN ONLY 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – General assets of the sponsorYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: PREMIUM PLAN ONLY 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedNo
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – General assets of the sponsorYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: PREMIUM PLAN ONLY 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)No
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – General assets of the sponsorYes
2009-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66944 )
Policy contract number011485
Policy instance 3
Insurance contract or identification number011485
Number of Individuals Covered4
Insurance policy start date2022-12-01
Insurance policy end date2023-11-30
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 $5,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
TDC - HUMANA (National Association of Insurance Commissioners NAIC id number: 07566 )
Policy contract number529599
Policy instance 2
Insurance contract or identification number529599
Number of Individuals Covered5
Insurance policy start date2022-11-01
Insurance policy end date2023-10-31
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 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 $2,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number660640
Policy instance 1
Insurance contract or identification number660640
Number of Individuals Covered3
Insurance policy start date2022-12-01
Insurance policy end date2023-11-30
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 $47,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
TDC - HUMANA (National Association of Insurance Commissioners NAIC id number: 07566 )
Policy contract number529599
Policy instance 2
Insurance contract or identification number529599
Number of Individuals Covered4
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
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 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 $9,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number660640
Policy instance 1
Insurance contract or identification number660640
Number of Individuals Covered3
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
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 $30,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
AXA EQUITABLE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66944 )
Policy contract number011485
Policy instance 3
Insurance contract or identification number011485
Number of Individuals Covered4
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
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 $1,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
TDC - HUMANA (National Association of Insurance Commissioners NAIC id number: 07566 )
Policy contract number529599
Policy instance 2
Insurance contract or identification number529599
Number of Individuals Covered8
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
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 $12,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number660640
Policy instance 1
Insurance contract or identification number660640
Number of Individuals Covered2
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
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 $28,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
TDC - HUMANA (National Association of Insurance Commissioners NAIC id number: 07566 )
Policy contract number529599
Policy instance 2
Insurance contract or identification number529599
Number of Individuals Covered10
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
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 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 $13,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number660640
Policy instance 1
Insurance contract or identification number660640
Number of Individuals Covered2
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
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 $32,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3

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