FIBRE FEDERAL CREDIT UNION has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2023: GROUP VISION INSURANCE PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-02-01 | 340 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-02-01 | 356 |
| Number of retired or separated participants receiving benefits | 2023-02-01 | 13 |
| Number of other retired or separated participants entitled to future benefits | 2023-02-01 | 0 |
| Total of all active and inactive participants | 2023-02-01 | 369 |
| Number of employers contributing to the scheme | 2023-02-01 | 0 |
| 2022: GROUP VISION INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 619 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 340 |
| Number of retired or separated participants receiving benefits | 2022-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-02-01 | 0 |
| Total of all active and inactive participants | 2022-02-01 | 340 |
| Number of employers contributing to the scheme | 2022-02-01 | 0 |
| 2021: GROUP VISION INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 366 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 615 |
| Number of retired or separated participants receiving benefits | 2021-02-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2021-02-01 | 0 |
| Total of all active and inactive participants | 2021-02-01 | 619 |
| Number of employers contributing to the scheme | 2021-02-01 | 0 |
| 2020: GROUP VISION INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 304 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 314 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 0 |
| Total of all active and inactive participants | 2020-02-01 | 314 |
| Number of employers contributing to the scheme | 2020-02-01 | 0 |
| 2019: GROUP VISION INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 294 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 308 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 308 |
| Number of employers contributing to the scheme | 2019-02-01 | 0 |
| 2018: GROUP VISION INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 595 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 572 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 17 |
| Total of all active and inactive participants | 2018-02-01 | 589 |
| Total participants | 2018-02-01 | 589 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Number of employers contributing to the scheme | 2018-02-01 | 0 |
| 2017: GROUP VISION INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 448 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 464 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 17 |
| Total of all active and inactive participants | 2017-02-01 | 481 |
| Total participants | 2017-02-01 | 481 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Number of employers contributing to the scheme | 2017-02-01 | 0 |
| 2016: GROUP VISION INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 98 |
| Total of all active and inactive participants | 2016-02-01 | 98 |
| Total participants | 2016-02-01 | 98 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Number of employers contributing to the scheme | 2016-02-01 | 0 |
| 2015: GROUP VISION INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 100 |
| Total of all active and inactive participants | 2015-06-01 | 100 |
| Total participants | 2015-06-01 | 100 |
| Total participants, beginning-of-year | 2015-05-01 | 42 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 0 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 0 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-05-01 | 0 |
| Total participants | 2015-05-01 | 0 |
| Number of participants with account balances | 2015-05-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2015-05-01 | 0 |
| Total participants, beginning-of-year | 2015-02-01 | 427 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 442 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 6 |
| Total of all active and inactive participants | 2015-02-01 | 448 |
| Total participants | 2015-02-01 | 448 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Number of employers contributing to the scheme | 2015-02-01 | 0 |
| 2014: GROUP VISION INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 413 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 425 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 2 |
| Total of all active and inactive participants | 2014-02-01 | 427 |
| Total participants | 2014-02-01 | 427 |
| 2013: GROUP VISION INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 415 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 412 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 1 |
| Total of all active and inactive participants | 2013-02-01 | 413 |
| Total participants | 2013-02-01 | 413 |
| 2012: GROUP VISION INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 393 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 414 |
| Number of retired or separated participants receiving benefits | 2012-02-01 | 1 |
| Total of all active and inactive participants | 2012-02-01 | 415 |
| Total participants | 2012-02-01 | 415 |
| 2011: GROUP VISION INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 153 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 2 |
| Total of all active and inactive participants | 2011-02-01 | 155 |
| Total participants | 2011-02-01 | 155 |
| 2009: GROUP VISION INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 149 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 146 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 149 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-02-01 | 1 |
| Total participants | 2009-02-01 | 150 |
| Number of participants with account balances | 2009-02-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-02-01 | 0 |
| 2023: GROUP VISION INSURANCE PLAN 2023 form 5500 responses |
|---|
| 2023-02-01 | Type of plan entity | Single employer plan |
| 2023-02-01 | Plan funding arrangement – Insurance | Yes |
| 2023-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: GROUP VISION INSURANCE PLAN 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: GROUP VISION INSURANCE PLAN 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: GROUP VISION INSURANCE PLAN 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: GROUP VISION INSURANCE PLAN 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: GROUP VISION INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | First time form 5500 has been submitted | Yes |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: GROUP VISION INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | First time form 5500 has been submitted | Yes |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: GROUP VISION INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | First time form 5500 has been submitted | Yes |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: GROUP VISION INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | First time form 5500 has been submitted | Yes |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | Yes |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: GROUP VISION INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | First time form 5500 has been submitted | Yes |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: GROUP VISION INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | First time form 5500 has been submitted | Yes |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: GROUP VISION INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | First time form 5500 has been submitted | Yes |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – Insurance | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: GROUP VISION INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | First time form 5500 has been submitted | Yes |
| 2011-02-01 | Submission has been amended | No |
| 2011-02-01 | This submission is the final filing | No |
| 2011-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-02-01 | Plan is a collectively bargained plan | No |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: GROUP VISION INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | First time form 5500 has been submitted | Yes |
| 2009-02-01 | Submission has been amended | No |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL0453572 |
| Policy instance | 4 |
| Insurance contract or identification number | ABL0453572 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $143 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 899599G |
| Policy instance | 3 |
| Insurance contract or identification number | 899599G | | Number of Individuals Covered | 356 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $15,423 | | Total amount of fees paid to insurance company | USD $7,197 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $129,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 9269 |
| Policy instance | 2 |
| Insurance contract or identification number | 9269 | | Number of Individuals Covered | 567 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $14,958 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 525 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $49,015 | | Total amount of fees paid to insurance company | USD $1,085 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,276,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | ABL453572 |
| Policy instance | 4 |
| Insurance contract or identification number | ABL453572 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 10568 |
| Policy instance | 3 |
| Insurance contract or identification number | 10568 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $10,684 | | Total amount of fees paid to insurance company | USD $1,977 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $157,060 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,684 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 9269 |
| Policy instance | 2 |
| Insurance contract or identification number | 9269 | | Number of Individuals Covered | 557 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,828 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $13,828 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 534 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $42,431 | | Total amount of fees paid to insurance company | USD $12 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,888,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,431 | | Amount paid for insurance broker fees | 12 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 9269 |
| Policy instance | 1 |
| Insurance contract or identification number | 9269 | | Number of Individuals Covered | 579 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $15,372 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,372 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 10568 |
| Policy instance | 2 |
| Insurance contract or identification number | 10568 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $10,664 | | Total amount of fees paid to insurance company | USD $1,872 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $151,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,664 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 3 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 1001 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $44,874 | | Total amount of fees paid to insurance company | USD $1,000 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,007,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,874 | | Amount paid for insurance broker fees | 1000 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 3 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 564 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $40,503 | | Total amount of fees paid to insurance company | USD $910 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,960,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,503 | | Amount paid for insurance broker fees | 910 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 10568 |
| Policy instance | 2 |
| Insurance contract or identification number | 10568 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $10,117 | | Total amount of fees paid to insurance company | USD $3,116 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $142,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,117 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 9269 |
| Policy instance | 1 |
| Insurance contract or identification number | 9269 | | Number of Individuals Covered | 592 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $15,228 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,228 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 9269 |
| Policy instance | 1 |
| Insurance contract or identification number | 9269 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $14,693 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,693 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 10568 |
| Policy instance | 2 |
| Insurance contract or identification number | 10568 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $13,486 | | Total amount of fees paid to insurance company | USD $100 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $153,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,952 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 3 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 553 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $48,364 | | Total amount of fees paid to insurance company | USD $1,563 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,990,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,364 | | Amount paid for insurance broker fees | 1563 | | Additional information about fees paid to insurance broker | 1ST QUARTER DOUBLE RETENTION BONUS | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 12378 |
| Policy instance | 3 |
| Insurance contract or identification number | 12378 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $14,862 | | Total amount of fees paid to insurance company | USD $32,692 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,862 | | Amount paid for insurance broker fees | 32692 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 2 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $9,257 | | Total amount of fees paid to insurance company | USD $155 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $614,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,257 | | Amount paid for insurance broker fees | 155 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 1 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $9,257 | | Total amount of fees paid to insurance company | USD $155 | | 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 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $614,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,257 | | Amount paid for insurance broker fees | 155 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 477 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $34,930 | | Total amount of fees paid to insurance company | USD $786 | | 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 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $2,322,047 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,930 | | Amount paid for insurance broker fees | 786 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 09269 |
| Policy instance | 1 |
| Insurance contract or identification number | 09269 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $14,862 | | Total amount of fees paid to insurance company | USD $32,692 | | 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 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 | Yes | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,862 | | Amount paid for insurance broker fees | 32692 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 481 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $36,332 | | Total amount of fees paid to insurance company | USD $891 | | 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 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $2,406,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $36,332 | | Amount paid for insurance broker fees | 891 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC - BE |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 1 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $9,632 | | Total amount of fees paid to insurance company | USD $176 | | 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 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $647,003 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,632 | | Amount paid for insurance broker fees | 176 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC - BE |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 09269 |
| Policy instance | 1 |
| Insurance contract or identification number | 09269 | | Number of Individuals Covered | 595 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $15,839 | | Total amount of fees paid to insurance company | USD $31,682 | | Are there contracts with allocated funds for individual policies? | 1 | | 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 | Yes | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $15,839 | | Amount paid for insurance broker fees | 31682 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 20389 |
| Policy instance | 2 |
| Insurance contract or identification number | 20389 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $9,632 | | Total amount of fees paid to insurance company | USD $176 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $647,003 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 12378 |
| Policy instance | 3 |
| Insurance contract or identification number | 12378 | | Number of Individuals Covered | 595 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $15,839 | | Total amount of fees paid to insurance company | USD $31,682 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $316,802 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 ) |
| Policy contract number | 12378 |
| Policy instance | 1 |
| Insurance contract or identification number | 12378 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $23,863 | | Are there contracts with allocated funds for individual policies? | Yes | | 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 | Yes | | 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 | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2386 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30058275 |
| Policy instance | 1 |
| Insurance contract or identification number | 30058275 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-02-01 | | Total amount of commissions paid to insurance broker | USD $381 | | 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $3,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 213 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
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| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10018768 |
| Policy instance | 2 |
| Insurance contract or identification number | 10018768 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $14,155 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $353,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,155 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 897 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $36,605 | | 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 | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $2,458,020 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $9,300 | | Total amount of fees paid to insurance company | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST BENEFIT CONSULTANTS INC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30058275 |
| Policy instance | 3 |
| Insurance contract or identification number | 30058275 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $380 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 213 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $35,119 | | 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 | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $2,358,264 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,119 | | Insurance broker name | INTERWEST BENEFIT CONSULTANTS INC |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 412 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $30,018 | | Total amount of fees paid to insurance company | USD $828 | | 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 | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $2,180,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,018 | | Amount paid for insurance broker fees | 828 | | Additional information about fees paid to insurance broker | RETENTION BONUS | | Insurance broker name | INTERWEST BENEFIT CONSULTANTS INC |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 414 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $36,805 | | Total amount of fees paid to insurance company | USD $753 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,284,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,805 | | Amount paid for insurance broker fees | 753 | | Insurance broker name | INTERWEST BENEFIT CONSULTANTS INC |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $27,621 | | Total amount of fees paid to insurance company | USD $739 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,025,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
| Policy contract number | 3060 |
| Policy instance | 1 |
| Insurance contract or identification number | 3060 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $28,075 | | Total amount of fees paid to insurance company | USD $776 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,888,165 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,075 | | Amount paid for insurance broker fees | 776 | | Additional information about fees paid to insurance broker | ENTERTAINMENT/BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | INTERWEST BENEFIT CONSULTANTS |
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