401k Plan data: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN plan

VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 401k Plan overview

Plan Name	VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN
Plan identification number	515

VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Other welfare benefit cover

401k Sponsoring company profile

BLUE CROSS AND BLUE SHIELD OF NEBRASKA has sponsored the creation of one or more 401k plans.

Company Name: BLUE CROSS AND BLUE SHIELD OF NEBRASKA

Employer identification number (EIN): 470095156

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
515 2016-01-01 CATHY FILIPIAK
515 2016-01-01
515 2015-09-01 BRAD SCHROEDER

Plan Statistics for VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN

401k plan membership statisitcs for VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN

Measure Date Value
2016: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 381
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
2015: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 227
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 381
Number of retired or separated participants receiving benefits 2015-09-01 0
Number of other retired or separated participants entitled to future benefits 2015-09-01 0
Total of all active and inactive participants 2015-09-01 381

Measure	Date	Value
2016: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	381
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
2015: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	227
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	381
Number of retired or separated participants receiving benefits	2015-09-01	0
Number of other retired or separated participants entitled to future benefits	2015-09-01	0
Total of all active and inactive participants	2015-09-01	381

Form 5500 Responses for VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN

2016: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	Yes
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: VOLUNTARY CRITICAL ILLNESS AND ACCIDENT PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	First time form 5500 has been submitted	Yes
2015-09-01	Submission has been amended	No
2015-09-01	This submission is the final filing	No
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-09-01	Plan is a collectively bargained plan	No
2015-09-01	Plan funding arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 )

Policy contract number

1000000155

Policy instance

Insurance contract or identification number	1000000155
Number of Individuals Covered	381
Insurance policy start date	2015-09-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,458
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY
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 Carrier	USD $34,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,458
Insurance broker organization code?	3
Insurance broker name	SILVERSTONE GROUP, INC

Potentially related plans

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Company Name:	BLUE CROSS AND BLUE SHIELD OF NEBRASKA
Employer identification number (EIN):	470095156
NAIC Classification:	524140

Plan id#	Filing Submission Date	Name of Administrator
515	2016-01-01	CATHY FILIPIAK
515	2016-01-01
515	2015-09-01	BRAD SCHROEDER