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ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 401k Plan overview

Plan NameROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN
Plan identification number 503

ROESSLER CHADWICK FOUNDATION WRAP 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)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

ROESSLER-CHADWICK FOUNDATION has sponsored the creation of one or more 401k plans.

Company Name:ROESSLER-CHADWICK FOUNDATION
Employer identification number (EIN):950615438
NAIC Classification:611000

Additional information about ROESSLER-CHADWICK FOUNDATION

Jurisdiction of Incorporation: California Department of State
Incorporation Date: 1963-01-21
Company Identification Number: C0444807
Legal Registered Office Address: 26800 S Academy Dr

Palos Verdes Peninsula
United States of America (USA)
90274

More information about ROESSLER-CHADWICK FOUNDATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032022-01-01KATIE DAVID2023-07-05
5032021-01-01KATIE DAVID2022-07-28
5032020-01-01KAITE DAVID2021-07-02
5032019-01-01JOHN KJENNER2020-07-17
5032018-01-01
5032017-01-01
5032016-10-01JOHN KJENNER
5032015-10-01JOHN KJENNER
5032015-07-01JOHN KJENNER
5032014-07-01JOHN KJENNER

Plan Statistics for ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN

401k plan membership statisitcs for ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN

Measure Date Value
2022: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01188
Total number of active participants reported on line 7a of the Form 55002022-01-01192
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01192
2021: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01183
Total number of active participants reported on line 7a of the Form 55002021-01-01182
Number of retired or separated participants receiving benefits2021-01-014
Number of other retired or separated participants entitled to future benefits2021-01-012
Total of all active and inactive participants2021-01-01188
2020: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01188
Total number of active participants reported on line 7a of the Form 55002020-01-01186
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 participants2020-01-01186
2019: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01183
Total number of active participants reported on line 7a of the Form 55002019-01-01188
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 participants2019-01-01188
2018: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01177
Total number of active participants reported on line 7a of the Form 55002018-01-01183
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 participants2018-01-01183
Number of employers contributing to the scheme2018-01-010
2017: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01177
Total number of active participants reported on line 7a of the Form 55002017-01-01176
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01176
2016: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01195
Total number of active participants reported on line 7a of the Form 55002016-10-01197
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01197
2015: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01186
Total number of active participants reported on line 7a of the Form 55002015-10-01194
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01194
Total participants, beginning-of-year2015-07-01173
Total number of active participants reported on line 7a of the Form 55002015-07-01177
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01177
2014: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01158
Total number of active participants reported on line 7a of the Form 55002014-07-01173
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01173

Form 5500 Responses for ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN

2022: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT 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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT 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: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – General assets of the sponsorYes
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: ROESSLER CHADWICK FOUNDATION WRAP BENEFIT PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01First time form 5500 has been submittedYes
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan funding arrangement – General assets of the sponsorYes
2014-07-01Plan benefit arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK605747
Policy instance 8
Insurance contract or identification numberSOK605747
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,021
Total amount of fees paid to insurance companyUSD $118
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $10,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,021
Amount paid for insurance broker fees118
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053469
Policy instance 1
Insurance contract or identification numberW0053469
Number of Individuals Covered340
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $113,773
Total amount of fees paid to insurance companyUSD $4,389
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 $2,210,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,198
Amount paid for insurance broker fees4389
Additional information about fees paid to insurance brokerCOMMISSIONS & FEES
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered371
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,951
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 $31,707
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,951
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number18665
Policy instance 3
Insurance contract or identification number18665
Number of Individuals Covered339
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,213
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 $205,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,213
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,473
Total amount of fees paid to insurance companyUSD $679
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
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 $54,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,473
Amount paid for insurance broker fees679
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD608350
Policy instance 5
Insurance contract or identification numberSGD608350
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,316
Total amount of fees paid to insurance companyUSD $115
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 BenefitNo
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 $13,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,316
Amount paid for insurance broker fees115
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number78826
Policy instance 6
Insurance contract or identification number78826
Number of Individuals Covered38
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $320
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 $8,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $320
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD608351
Policy instance 7
Insurance contract or identification numberSGD608351
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,778
Total amount of fees paid to insurance companyUSD $205
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $17,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,778
Amount paid for insurance broker fees205
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered366
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,351
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 $23,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,351
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number18665
Policy instance 3
Insurance contract or identification number18665
Number of Individuals Covered326
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $8,371
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 $201,042
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,371
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Number of Individuals Covered182
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,219
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 BenefitNo
Life Insurance Welfare BenefitYes
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 $42,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,219
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD608350
Policy instance 5
Insurance contract or identification numberSGD608350
Number of Individuals Covered182
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $755
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 BenefitNo
Life Insurance Welfare BenefitNo
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 $7,551
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $755
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number78826
Policy instance 6
Insurance contract or identification number78826
Number of Individuals Covered44
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $292
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 $7,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $292
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD608351
Policy instance 7
Insurance contract or identification numberSGD608351
Number of Individuals Covered182
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,378
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 BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
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 $13,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,378
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK605747
Policy instance 8
Insurance contract or identification numberSOK605747
Number of Individuals Covered182
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $765
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 BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
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 $7,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $765
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053469
Policy instance 1
Insurance contract or identification numberW0053469
Number of Individuals Covered326
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $42,830
Total amount of fees paid to insurance companyUSD $64,209
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 $2,077,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees64209
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Number of Individuals Covered190
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,703
Total amount of fees paid to insurance companyUSD $731
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
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 $57,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,703
Amount paid for insurance broker fees731
Additional information about fees paid to insurance brokerCOMMISSIONS AND FEES
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number18665
Policy instance 3
Insurance contract or identification number18665
Number of Individuals Covered329
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $8,511
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 $212,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $8,511
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered368
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,545
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 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 $21,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,545
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053469
Policy instance 1
Insurance contract or identification numberW0053469
Number of Individuals Covered330
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $39,293
Total amount of fees paid to insurance companyUSD $64,089
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 $1,905,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees64089
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 numberW0053469
Policy instance 1
Insurance contract or identification numberW0053469
Number of Individuals Covered319
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $36,095
Total amount of fees paid to insurance companyUSD $55,677
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 $1,750,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees55677
Additional information about fees paid to insurance brokerBONUS OVERRIDE NON-MONETARY COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered363
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,231
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 $24,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,231
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number18665
Policy instance 3
Insurance contract or identification number18665
Number of Individuals Covered357
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,315
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 $182,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $7,315
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Number of Individuals Covered188
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,247
Total amount of fees paid to insurance companyUSD $514
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
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 $72,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,247
Amount paid for insurance broker fees514
Additional information about fees paid to insurance brokerCOMMISSIONS AND FEES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053469
Policy instance 1
Insurance contract or identification numberW0053469
Number of Individuals Covered304
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $115,782
Total amount of fees paid to insurance companyUSD $2,137
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,822,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,114
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS OVERRIDE NON-MONETARY COMPENSATION
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered347
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,930
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,347
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number18665
Policy instance 3
Insurance contract or identification number18665
Number of Individuals Covered298
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,487
Total amount of fees paid to insurance companyUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $176,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $6,487
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Number of Individuals Covered183
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $6,780
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $67,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $6,780
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM607880
Policy instance 4
Insurance contract or identification numberSGM607880
Number of Individuals Covered176
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $5,828
Total amount of fees paid to insurance companyUSD $1,544
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 providedEMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $58,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,828
Amount paid for insurance broker fees1544
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0053469
Policy instance 3
Insurance contract or identification numberW0053469
Number of Individuals Covered303
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $56,062
Total amount of fees paid to insurance companyUSD $1,600
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,868,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $56,062
Amount paid for insurance broker fees1600
Additional information about fees paid to insurance brokerBONUS OVERRIDE
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10086411001
Policy instance 2
Insurance contract or identification number10086411001
Number of Individuals Covered335
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $201
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $201
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number5043
Policy instance 1
Insurance contract or identification number5043
Number of Individuals Covered11
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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