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DERMIRA, INC. MEDICAL PLAN 401k Plan overview

Plan NameDERMIRA, INC. MEDICAL PLAN
Plan identification number 501

DERMIRA, INC. MEDICAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Prepaid legal
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

DERMIRA, INC. has sponsored the creation of one or more 401k plans.

Company Name:DERMIRA, INC.
Employer identification number (EIN):273267680
NAIC Classification:541700

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DERMIRA, INC. MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-01-01JOHN P. SCHARF2022-07-01
5012020-01-01TRACY VANDENBERG2021-06-24
5012019-01-01ANDREW GUGGENHIME2020-04-16
5012018-01-01
5012017-12-01

Plan Statistics for DERMIRA, INC. MEDICAL PLAN

401k plan membership statisitcs for DERMIRA, INC. MEDICAL PLAN

Measure Date Value
2021: DERMIRA, INC. MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01189
Total number of active participants reported on line 7a of the Form 55002021-01-0120
Number of retired or separated participants receiving benefits2021-01-014
Number of other retired or separated participants entitled to future benefits2021-01-0117
Total of all active and inactive participants2021-01-0141
Number of employers contributing to the scheme2021-01-010
2020: DERMIRA, INC. MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01324
Total number of active participants reported on line 7a of the Form 55002020-01-01189
Number of retired or separated participants receiving benefits2020-01-017
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01196
Number of employers contributing to the scheme2020-01-010
2019: DERMIRA, INC. MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01335
Total number of active participants reported on line 7a of the Form 55002019-01-01321
Number of retired or separated participants receiving benefits2019-01-013
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01324
Number of employers contributing to the scheme2019-01-010
2018: DERMIRA, INC. MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01155
Total number of active participants reported on line 7a of the Form 55002018-01-01331
Number of retired or separated participants receiving benefits2018-01-014
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01335
Number of employers contributing to the scheme2018-01-010
2017: DERMIRA, INC. MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01152
Total number of active participants reported on line 7a of the Form 55002017-12-01152
Number of retired or separated participants receiving benefits2017-12-010
Number of other retired or separated participants entitled to future benefits2017-12-013
Total of all active and inactive participants2017-12-01155

Form 5500 Responses for DERMIRA, INC. MEDICAL PLAN

2021: DERMIRA, INC. MEDICAL PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DERMIRA, INC. MEDICAL PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: DERMIRA, INC. MEDICAL PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: DERMIRA, INC. MEDICAL PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: DERMIRA, INC. MEDICAL PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01First time form 5500 has been submittedYes
2017-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-12-01Plan funding arrangement – InsuranceYes
2017-12-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number167401
Policy instance 6
Insurance contract or identification number167401
Number of Individuals Covered73
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $68,960
Total amount of fees paid to insurance companyUSD $14,960
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,238,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,960
Amount paid for insurance broker fees14960
Additional information about fees paid to insurance broker2021 NEW SALES CREDIT AND NEW BUSINESS INCENTIVE
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19181
Policy instance 1
Insurance contract or identification number19181
Number of Individuals Covered48
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $17,724
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $161,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $17,724
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30053712
Policy instance 2
Insurance contract or identification number30053712
Number of Individuals Covered28
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,897
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,758
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )
Policy contract number11919
Policy instance 3
Insurance contract or identification number11919
Number of Individuals Covered4
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $3,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number53459
Policy instance 4
Insurance contract or identification number53459
Number of Individuals Covered6
Insurance policy start date2021-01-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $6,916
Total amount of fees paid to insurance companyUSD $4,695
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $68,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,916
Amount paid for insurance broker fees4677
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )
Policy contract number186050001001
Policy instance 5
Insurance contract or identification number186050001001
Number of Individuals Covered8
Insurance policy start date2021-01-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $393
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $3,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $393
Amount paid for insurance broker fees0
Insurance broker organization code?3
ARAG INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 34738 )
Policy contract number186050001001
Policy instance 6
Insurance contract or identification number186050001001
Number of Individuals Covered44
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $939
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $9,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $939
Amount paid for insurance broker fees0
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number53459
Policy instance 5
Insurance contract or identification number53459
Number of Individuals Covered192
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $21,457
Total amount of fees paid to insurance companyUSD $12,259
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $212,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,457
Amount paid for insurance broker fees7834
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )
Policy contract number11919
Policy instance 4
Insurance contract or identification number11919
Number of Individuals Covered192
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $8,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30053712
Policy instance 3
Insurance contract or identification number30053712
Number of Individuals Covered213
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,887
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $74,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,738
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19181
Policy instance 2
Insurance contract or identification number19181
Number of Individuals Covered572
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $42,402
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $424,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $42,402
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0063517
Policy instance 1
Insurance contract or identification numberW0063517
Number of Individuals Covered562
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $235,458
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,114,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees167571
Additional information about fees paid to insurance brokerPRODUCER SERVICE FEES BONUS OVERRIDE
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number53459
Policy instance 5
Insurance contract or identification number53459
Number of Individuals Covered323
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $25,699
Total amount of fees paid to insurance companyUSD $106
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $255,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,937
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerTHIRD PARTY ADMINISTRATION FEES
CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )
Policy contract number11919
Policy instance 4
Insurance contract or identification number11919
Number of Individuals Covered326
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $8,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30053712
Policy instance 3
Insurance contract or identification number30053712
Number of Individuals Covered302
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,447
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $89,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,127
Amount paid for insurance broker fees0
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19181
Policy instance 2
Insurance contract or identification number19181
Number of Individuals Covered816
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $64,303
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $643,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $37,069
Amount paid for insurance broker fees0
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0063517
Policy instance 1
Insurance contract or identification numberW0063517
Number of Individuals Covered790
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,883
Total amount of fees paid to insurance companyUSD $306,286
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,317,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees108992
Additional information about fees paid to insurance brokerGENERAL AGENT SERVICES
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0063517
Policy instance 1
Insurance contract or identification numberW0063517
Number of Individuals Covered892
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $334,601
Total amount of fees paid to insurance companyUSD $1,208
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,699,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $234,962
Amount paid for insurance broker fees1208
Additional information about fees paid to insurance brokerBONUS OVERRIDE NON-MONETARY COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19181
Policy instance 2
Insurance contract or identification number19181
Number of Individuals Covered929
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $52,056
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $520,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $52,056
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30053712
Policy instance 3
Insurance contract or identification number30053712
Number of Individuals Covered323
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,660
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $66,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,337
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )
Policy contract number11919
Policy instance 4
Insurance contract or identification number11919
Number of Individuals Covered223
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $225
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $4,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $225
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM608649
Policy instance 5
Insurance contract or identification numberSGM608649
Number of Individuals Covered331
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $16,669
Total amount of fees paid to insurance companyUSD $2,231
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $166,688
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $16,669
Amount paid for insurance broker fees2231
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW0063517
Policy instance 1
Insurance contract or identification numberW0063517
Number of Individuals Covered420
Insurance policy start date2017-12-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $14,135
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $282,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,135
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC

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