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CLUB ASSIST US HEALTH AND WELFARE PLANS 401k Plan overview

Plan NameCLUB ASSIST US HEALTH AND WELFARE PLANS
Plan identification number 501

CLUB ASSIST US HEALTH AND WELFARE PLANS Benefits

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

401k Sponsoring company profile

CLUB ASSIST US, LLC has sponsored the creation of one or more 401k plans.

Company Name:CLUB ASSIST US, LLC
Employer identification number (EIN):980361710
NAIC Classification:423100

Additional information about CLUB ASSIST US, LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 200214210033

More information about CLUB ASSIST US, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLUB ASSIST US HEALTH AND WELFARE PLANS

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01MARCIE LUSHEN2023-09-26
5012021-07-01MARCIE LUSHEN2022-08-05
5012020-07-01MARCIE LUSHEN2022-02-04
5012019-07-01MARIA RANDALL2020-12-22
5012018-07-01MARIA RANDALL2019-12-23
5012017-07-01
5012016-07-01
5012015-07-01MARIA RANDALL
5012014-07-01CATHY COOK
5012013-07-01KATHY FLORES
5012012-07-01LORI SHORT
5012011-07-01KATHY FLORES
5012010-07-01KATHY FLORES
5012009-07-01KATHY FLORES

Plan Statistics for CLUB ASSIST US HEALTH AND WELFARE PLANS

401k plan membership statisitcs for CLUB ASSIST US HEALTH AND WELFARE PLANS

Measure Date Value
2022: CLUB ASSIST US HEALTH AND WELFARE PLANS 2022 401k membership
Total participants, beginning-of-year2022-01-01227
Total number of active participants reported on line 7a of the Form 55002022-01-01157
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 participants2022-01-01157
Number of employers contributing to the scheme2022-01-010
2021: CLUB ASSIST US HEALTH AND WELFARE PLANS 2021 401k membership
Total participants, beginning-of-year2021-07-01236
Total number of active participants reported on line 7a of the Form 55002021-07-01226
Number of retired or separated participants receiving benefits2021-07-011
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01227
Number of employers contributing to the scheme2021-07-010
2020: CLUB ASSIST US HEALTH AND WELFARE PLANS 2020 401k membership
Total participants, beginning-of-year2020-07-01224
Total number of active participants reported on line 7a of the Form 55002020-07-01236
Number of retired or separated participants receiving benefits2020-07-014
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01240
2019: CLUB ASSIST US HEALTH AND WELFARE PLANS 2019 401k membership
Total participants, beginning-of-year2019-07-01208
Total number of active participants reported on line 7a of the Form 55002019-07-01224
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01224
Number of employers contributing to the scheme2019-07-010
2018: CLUB ASSIST US HEALTH AND WELFARE PLANS 2018 401k membership
Total participants, beginning-of-year2018-07-01196
Total number of active participants reported on line 7a of the Form 55002018-07-01208
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01208
Number of employers contributing to the scheme2018-07-010
2017: CLUB ASSIST US HEALTH AND WELFARE PLANS 2017 401k membership
Total participants, beginning-of-year2017-07-01177
Total number of active participants reported on line 7a of the Form 55002017-07-01196
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01196
2016: CLUB ASSIST US HEALTH AND WELFARE PLANS 2016 401k membership
Total participants, beginning-of-year2016-07-01175
Total number of active participants reported on line 7a of the Form 55002016-07-01177
Number of retired or separated participants receiving benefits2016-07-010
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01177
2015: CLUB ASSIST US HEALTH AND WELFARE PLANS 2015 401k membership
Total participants, beginning-of-year2015-07-01193
Total number of active participants reported on line 7a of the Form 55002015-07-01175
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 participants2015-07-01175
2014: CLUB ASSIST US HEALTH AND WELFARE PLANS 2014 401k membership
Total participants, beginning-of-year2014-07-01152
Total number of active participants reported on line 7a of the Form 55002014-07-01146
Number of retired or separated participants receiving benefits2014-07-012
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01148
2013: CLUB ASSIST US HEALTH AND WELFARE PLANS 2013 401k membership
Total participants, beginning-of-year2013-07-01155
Total number of active participants reported on line 7a of the Form 55002013-07-01152
Number of retired or separated participants receiving benefits2013-07-010
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-01152
2012: CLUB ASSIST US HEALTH AND WELFARE PLANS 2012 401k membership
Total participants, beginning-of-year2012-07-01134
Total number of active participants reported on line 7a of the Form 55002012-07-01155
Number of retired or separated participants receiving benefits2012-07-010
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01155
2011: CLUB ASSIST US HEALTH AND WELFARE PLANS 2011 401k membership
Total participants, beginning-of-year2011-07-01357
Total number of active participants reported on line 7a of the Form 55002011-07-01131
Number of retired or separated participants receiving benefits2011-07-013
Number of other retired or separated participants entitled to future benefits2011-07-010
Total of all active and inactive participants2011-07-01134
2010: CLUB ASSIST US HEALTH AND WELFARE PLANS 2010 401k membership
Total participants, beginning-of-year2010-07-01208
Total number of active participants reported on line 7a of the Form 55002010-07-01354
Number of retired or separated participants receiving benefits2010-07-013
Number of other retired or separated participants entitled to future benefits2010-07-010
Total of all active and inactive participants2010-07-01357
2009: CLUB ASSIST US HEALTH AND WELFARE PLANS 2009 401k membership
Total participants, beginning-of-year2009-07-01250
Total number of active participants reported on line 7a of the Form 55002009-07-01204
Number of retired or separated participants receiving benefits2009-07-014
Number of other retired or separated participants entitled to future benefits2009-07-010
Total of all active and inactive participants2009-07-01208

Form 5500 Responses for CLUB ASSIST US HEALTH AND WELFARE PLANS

2022: CLUB ASSIST US HEALTH AND WELFARE PLANS 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: CLUB ASSIST US HEALTH AND WELFARE PLANS 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: CLUB ASSIST US HEALTH AND WELFARE PLANS 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: CLUB ASSIST US HEALTH AND WELFARE PLANS 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: CLUB ASSIST US HEALTH AND WELFARE PLANS 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – General assets of the sponsorYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – General assets of the sponsorYes
2017: CLUB ASSIST US HEALTH AND WELFARE PLANS 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan funding arrangement – General assets of the sponsorYes
2017-07-01Plan benefit arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – General assets of the sponsorYes
2016: CLUB ASSIST US HEALTH AND WELFARE PLANS 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan funding arrangement – General assets of the sponsorYes
2016-07-01Plan benefit arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – General assets of the sponsorYes
2015: CLUB ASSIST US HEALTH AND WELFARE PLANS 2015 form 5500 responses
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)No
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: CLUB ASSIST US HEALTH AND WELFARE PLANS 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
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 benefit arrangement – InsuranceYes
2013: CLUB ASSIST US HEALTH AND WELFARE PLANS 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: CLUB ASSIST US HEALTH AND WELFARE PLANS 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan funding arrangement – General assets of the sponsorYes
2012-07-01Plan benefit arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – General assets of the sponsorYes
2011: CLUB ASSIST US HEALTH AND WELFARE PLANS 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2010: CLUB ASSIST US HEALTH AND WELFARE PLANS 2010 form 5500 responses
2010-07-01Type of plan entitySingle employer plan
2010-07-01Submission has been amendedNo
2010-07-01This submission is the final filingNo
2010-07-01This return/report is a short plan year return/report (less than 12 months)No
2010-07-01Plan is a collectively bargained planNo
2010-07-01Plan funding arrangement – InsuranceYes
2010-07-01Plan benefit arrangement – InsuranceYes
2009: CLUB ASSIST US HEALTH AND WELFARE PLANS 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01Submission has been amendedNo
2009-07-01This submission is the final filingNo
2009-07-01This return/report is a short plan year return/report (less than 12 months)No
2009-07-01Plan is a collectively bargained planNo
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number917654
Policy instance 3
Insurance contract or identification number917654
Number of Individuals Covered272
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $25,048
Total amount of fees paid to insurance companyUSD $48,270
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
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 $1,700,731
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,751
Amount paid for insurance broker fees30028
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 2
Insurance contract or identification number400200000
Number of Individuals Covered15
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,298
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $11,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,030
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number204305
Policy instance 1
Insurance contract or identification number204305
Number of Individuals Covered161
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $677
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $3,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $542
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 2
Insurance contract or identification number400200000
Number of Individuals Covered28
Insurance policy start date2021-07-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $885
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $8,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $703
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number917654
Policy instance 3
Insurance contract or identification number917654
Number of Individuals Covered552
Insurance policy start date2021-07-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,579
Total amount of fees paid to insurance companyUSD $17,019
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
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 $1,013,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,579
Amount paid for insurance broker fees17019
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number204305
Policy instance 1
Insurance contract or identification number204305
Number of Individuals Covered18
Insurance policy start date2021-07-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $318
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $1,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $318
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 2
Insurance contract or identification number400200000
Number of Individuals Covered29
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $1,614
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 providedACCIDENT,CRITICAL ILLNESS
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 $10,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,317
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number204305
Policy instance 1
Insurance contract or identification number204305
Number of Individuals Covered25
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $612
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 providedLEGAL
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 $4,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $438
Insurance broker organization code?4
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number917654
Policy instance 3
Insurance contract or identification number917654
Number of Individuals Covered408
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $19,905
Total amount of fees paid to insurance companyUSD $55,292
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 BenefitYes
Vision Insurance Welfare BenefitYes
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 $1,991,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,905
Amount paid for insurance broker fees55292
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 2
Insurance contract or identification number400200000
Number of Individuals Covered35
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $4,227
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $22,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,817
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number149346
Policy instance 1
Insurance contract or identification number149346
Number of Individuals Covered25
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $397
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $2,446
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $213
Amount paid for insurance broker fees0
Insurance broker organization code?4
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number917654
Policy instance 3
Insurance contract or identification number917654
Number of Individuals Covered306
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $46,391
Total amount of fees paid to insurance companyUSD $59,346
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
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 $1,865,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,603
Amount paid for insurance broker fees55217
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 4
Insurance contract or identification number400200000
Number of Individuals Covered29
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $3,083
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $15,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,004
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number149346
Policy instance 3
Insurance contract or identification number149346
Number of Individuals Covered29
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $2,191
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $3,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,143
Amount paid for insurance broker fees0
Insurance broker organization code?4
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number276606
Policy instance 2
Insurance contract or identification number276606
Number of Individuals Covered257
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $111,606
Total amount of fees paid to insurance companyUSD $6,728
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $1,593,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $105,277
Amount paid for insurance broker fees6728
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number5977081
Policy instance 1
Insurance contract or identification number5977081
Number of Individuals Covered184
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $14,506
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $145,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $14,506
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 )
Policy contract number400200000
Policy instance 4
Insurance contract or identification number400200000
Number of Individuals Covered29
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $5,224
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $18,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,396
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameDAVID MORRIS
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number149346
Policy instance 3
Insurance contract or identification number149346
Number of Individuals Covered25
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $761
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $1,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $720
Amount paid for insurance broker fees0
Insurance broker organization code?4
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number276606
Policy instance 2
Insurance contract or identification number276606
Number of Individuals Covered235
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $70,019
Total amount of fees paid to insurance companyUSD $5,418
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $1,538,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70,019
Amount paid for insurance broker fees5418
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract numberACA5977081
Policy instance 1
Insurance contract or identification numberACA5977081
Number of Individuals Covered172
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $25,058
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $125,291
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,529
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerDID NOT PROVIDE THE ADDRESS FOR THE AGENT/BROKER.
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.

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