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KEYSTONE ADOLESCENT CENTER, INC. 401k Plan overview

Plan NameKEYSTONE ADOLESCENT CENTER, INC.
Plan identification number 501

KEYSTONE ADOLESCENT CENTER, INC. Benefits

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

401k Sponsoring company profile

KEYSTONE ADOLESCENT CENTER, INC. has sponsored the creation of one or more 401k plans.

Company Name:KEYSTONE ADOLESCENT CENTER, INC.
Employer identification number (EIN):251710410
NAIC Classification:624100
NAIC Description: Individual and Family Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KEYSTONE ADOLESCENT CENTER, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01JAMES GENTILE2023-06-19
5012021-01-01JAMES GENTILE2022-06-29
5012020-01-01JAMES GENTILE2021-08-16
5012019-01-01JAMES GENTILE2020-07-27
5012018-01-01
5012017-01-01
5012016-01-01
5012016-01-01
5012015-01-01
5012014-01-01
5012013-01-01
5012012-01-01JAMES GENTILE
5012011-01-01JAMES GENTILE
5012009-01-01KEYSTONE ADOLESCENT CENTER2010-05-19 KEYSTONE ADOLESCENT CENTER2010-05-19

Plan Statistics for KEYSTONE ADOLESCENT CENTER, INC.

401k plan membership statisitcs for KEYSTONE ADOLESCENT CENTER, INC.

Measure Date Value
2022: KEYSTONE ADOLESCENT CENTER, INC. 2022 401k membership
Total participants, beginning-of-year2022-01-01293
Total number of active participants reported on line 7a of the Form 55002022-01-01266
Total of all active and inactive participants2022-01-01266
2021: KEYSTONE ADOLESCENT CENTER, INC. 2021 401k membership
Total participants, beginning-of-year2021-01-01282
Total number of active participants reported on line 7a of the Form 55002021-01-01293
Total of all active and inactive participants2021-01-01293
2020: KEYSTONE ADOLESCENT CENTER, INC. 2020 401k membership
Total participants, beginning-of-year2020-01-01266
Total number of active participants reported on line 7a of the Form 55002020-01-01282
Total of all active and inactive participants2020-01-01282
2019: KEYSTONE ADOLESCENT CENTER, INC. 2019 401k membership
Total participants, beginning-of-year2019-01-01253
Total number of active participants reported on line 7a of the Form 55002019-01-01266
Total of all active and inactive participants2019-01-01266
2018: KEYSTONE ADOLESCENT CENTER, INC. 2018 401k membership
Total participants, beginning-of-year2018-01-01212
Total number of active participants reported on line 7a of the Form 55002018-01-01253
Total of all active and inactive participants2018-01-01253
2017: KEYSTONE ADOLESCENT CENTER, INC. 2017 401k membership
Total participants, beginning-of-year2017-01-01180
Total number of active participants reported on line 7a of the Form 55002017-01-01212
Total of all active and inactive participants2017-01-01212
2016: KEYSTONE ADOLESCENT CENTER, INC. 2016 401k membership
Total participants, beginning-of-year2016-01-01166
Total number of active participants reported on line 7a of the Form 55002016-01-01122
Total of all active and inactive participants2016-01-01122
2015: KEYSTONE ADOLESCENT CENTER, INC. 2015 401k membership
Total participants, beginning-of-year2015-01-01168
Total number of active participants reported on line 7a of the Form 55002015-01-01166
Total of all active and inactive participants2015-01-01166
2014: KEYSTONE ADOLESCENT CENTER, INC. 2014 401k membership
Total participants, beginning-of-year2014-01-01235
Total number of active participants reported on line 7a of the Form 55002014-01-01168
Total of all active and inactive participants2014-01-01168
2013: KEYSTONE ADOLESCENT CENTER, INC. 2013 401k membership
Total participants, beginning-of-year2013-01-01259
Total number of active participants reported on line 7a of the Form 55002013-01-01235
Total of all active and inactive participants2013-01-01235
2012: KEYSTONE ADOLESCENT CENTER, INC. 2012 401k membership
Total participants, beginning-of-year2012-01-01278
Total number of active participants reported on line 7a of the Form 55002012-01-01259
Total of all active and inactive participants2012-01-01259
2011: KEYSTONE ADOLESCENT CENTER, INC. 2011 401k membership
Total participants, beginning-of-year2011-01-01283
Total number of active participants reported on line 7a of the Form 55002011-01-01278
Total of all active and inactive participants2011-01-01278
2009: KEYSTONE ADOLESCENT CENTER, INC. 2009 401k membership
Total participants, beginning-of-year2009-01-01286
Total number of active participants reported on line 7a of the Form 55002009-01-01296
Total of all active and inactive participants2009-01-01296

Form 5500 Responses for KEYSTONE ADOLESCENT CENTER, INC.

2022: KEYSTONE ADOLESCENT CENTER, INC. 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: KEYSTONE ADOLESCENT CENTER, INC. 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: KEYSTONE ADOLESCENT CENTER, INC. 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: KEYSTONE ADOLESCENT CENTER, INC. 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: KEYSTONE ADOLESCENT CENTER, INC. 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: KEYSTONE ADOLESCENT CENTER, INC. 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: KEYSTONE ADOLESCENT CENTER, INC. 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: KEYSTONE ADOLESCENT CENTER, INC. 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: KEYSTONE ADOLESCENT CENTER, INC. 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: KEYSTONE ADOLESCENT CENTER, INC. 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: KEYSTONE ADOLESCENT CENTER, INC. 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: KEYSTONE ADOLESCENT CENTER, INC. 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: KEYSTONE ADOLESCENT CENTER, INC. 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered105
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $9,418
Total amount of fees paid to insurance companyUSD $3,402
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $75,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,418
Amount paid for insurance broker fees3402
Insurance broker organization code?3
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number284941
Policy instance 1
Insurance contract or identification number284941
Number of Individuals Covered161
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $18,150
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $635,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,150
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered119
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $7,323
Total amount of fees paid to insurance companyUSD $5,149
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $67,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,323
Amount paid for insurance broker fees5149
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number900583301
Policy instance 1
Insurance contract or identification number900583301
Number of Individuals Covered174
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $24,474
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $636,143
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,474
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number900583300
Policy instance 1
Insurance contract or identification number900583300
Number of Individuals Covered171
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $24,418
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $639,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,418
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered111
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $6,920
Total amount of fees paid to insurance companyUSD $3,806
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $66,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,920
Amount paid for insurance broker fees3806
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered115
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $4,247
Total amount of fees paid to insurance companyUSD $2,845
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $39,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,247
Amount paid for insurance broker fees2845
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number900583300
Policy instance 1
Insurance contract or identification number900583300
Number of Individuals Covered151
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $21,733
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $520,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,733
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered100
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $4,732
Total amount of fees paid to insurance companyUSD $3,293
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $44,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,732
Amount paid for insurance broker fees3293
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number900583300
Policy instance 1
Insurance contract or identification number900583300
Number of Individuals Covered153
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $19,435
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $528,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,435
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered122
Insurance policy start date2016-05-01
Insurance policy end date2017-04-30
Total amount of commissions paid to insurance brokerUSD $5,151
Total amount of fees paid to insurance companyUSD $2,700
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,151
Amount paid for insurance broker fees2700
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number696922
Policy instance 1
Insurance contract or identification number696922
Number of Individuals Covered90
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $13,984
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $243,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,984
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90212622
Policy instance 1
Insurance contract or identification number90212622
Number of Individuals Covered53
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $15,144
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $352,404
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,144
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered113
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $4,927
Total amount of fees paid to insurance companyUSD $2,652
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $52,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,927
Amount paid for insurance broker fees2652
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number90212622
Policy instance 1
Insurance contract or identification number90212622
Number of Individuals Covered52
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $18,704
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $361,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,704
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00369051
Policy instance 2
Insurance contract or identification number00369051
Number of Individuals Covered116
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $5,311
Total amount of fees paid to insurance companyUSD $3,900
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $59,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,311
Amount paid for insurance broker fees3900
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
HEALTHAMERICA OF PENNSYLVANIA, INC. (National Association of Insurance Commissioners NAIC id number: 95060 )
Policy contract number5925850000
Policy instance 1
Insurance contract or identification number5925850000
Number of Individuals Covered235
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $32,093
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $802,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,093
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 2
Insurance contract or identification number1251500-1251571
Number of Individuals Covered259
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $21,797
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $756,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,797
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 1
Insurance contract or identification number1251500-1251571
Number of Individuals Covered259
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,254
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $147,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,254
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 1
Insurance contract or identification number1251500-1251571
Number of Individuals Covered278
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $4,644
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $154,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 2
Insurance contract or identification number1251500-1251571
Number of Individuals Covered278
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $24,036
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $793,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 1
Insurance contract or identification number1251500-1251571
Number of Individuals Covered283
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $6,229
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $207,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,229
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS
HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )
Policy contract number1251500-1251571
Policy instance 2
Insurance contract or identification number1251500-1251571
Number of Individuals Covered283
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $21,196
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $706,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,196
Insurance broker organization code?3
Insurance broker nameDAVEVIC BENEFIT CONSULTANTS

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