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CHA HEALTH SYSTEMS MEDICAL PLAN 401k Plan overview

Plan NameCHA HEALTH SYSTEMS MEDICAL PLAN
Plan identification number 501

CHA HEALTH SYSTEMS MEDICAL PLAN Benefits

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

401k Sponsoring company profile

CHA HEALTH SYSTEMS, HOLLYWOOD PRESBYTERIAN MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name:CHA HEALTH SYSTEMS, HOLLYWOOD PRESBYTERIAN MEDICAL CENTER
Employer identification number (EIN):300284087
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHA HEALTH SYSTEMS MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012018-01-01IRENE RUIZ IRENE RUIZ2019-06-13
5012017-01-01IRINA CONSTANTIN IRINA CONSTANTIN2018-10-10
5012016-01-01GEORGE LEISHER
5012015-01-01GEORGE LOY LEISHER JR
5012014-01-01NORMA BRAUN
5012013-01-01NORMA BRAUN
5012012-01-01NORMA BRAUN NORMA BRAUN2013-07-12
5012011-01-01NORMA BRAUN
5012010-01-01NORMA BRAUN
5012009-02-01NORMA BRAUN

Plan Statistics for CHA HEALTH SYSTEMS MEDICAL PLAN

401k plan membership statisitcs for CHA HEALTH SYSTEMS MEDICAL PLAN

Measure Date Value
2018: CHA HEALTH SYSTEMS MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-011,308
Total number of active participants reported on line 7a of the Form 55002018-01-010
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-010
2017: CHA HEALTH SYSTEMS MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-011,223
Total number of active participants reported on line 7a of the Form 55002017-01-011,298
Number of retired or separated participants receiving benefits2017-01-0110
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-011,308
2016: CHA HEALTH SYSTEMS MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-011,064
Total number of active participants reported on line 7a of the Form 55002016-01-011,223
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-011,223
2015: CHA HEALTH SYSTEMS MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-011,072
Total number of active participants reported on line 7a of the Form 55002015-01-011,047
Number of retired or separated participants receiving benefits2015-01-0117
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-011,064
2014: CHA HEALTH SYSTEMS MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01925
Total number of active participants reported on line 7a of the Form 55002014-01-011,065
Number of retired or separated participants receiving benefits2014-01-017
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-011,072
2013: CHA HEALTH SYSTEMS MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01851
Total number of active participants reported on line 7a of the Form 55002013-01-01912
Number of retired or separated participants receiving benefits2013-01-0113
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01925
2012: CHA HEALTH SYSTEMS MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-011,018
Total number of active participants reported on line 7a of the Form 55002012-01-01830
Number of retired or separated participants receiving benefits2012-01-0121
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01851
2011: CHA HEALTH SYSTEMS MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01948
Total number of active participants reported on line 7a of the Form 55002011-01-011,004
Number of retired or separated participants receiving benefits2011-01-0114
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-011,018
2010: CHA HEALTH SYSTEMS MEDICAL PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-011,234
Total number of active participants reported on line 7a of the Form 55002010-01-01923
Number of retired or separated participants receiving benefits2010-01-0125
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01948
2009: CHA HEALTH SYSTEMS MEDICAL PLAN 2009 401k membership
Total participants, beginning-of-year2009-02-011,271
Total number of active participants reported on line 7a of the Form 55002009-02-011,217
Number of retired or separated participants receiving benefits2009-02-0112
Number of other retired or separated participants entitled to future benefits2009-02-015
Total of all active and inactive participants2009-02-011,234

Form 5500 Responses for CHA HEALTH SYSTEMS MEDICAL PLAN

2018: CHA HEALTH SYSTEMS MEDICAL PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingYes
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
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: CHA HEALTH SYSTEMS MEDICAL PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: CHA HEALTH SYSTEMS MEDICAL PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: CHA HEALTH SYSTEMS MEDICAL PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: CHA HEALTH SYSTEMS MEDICAL PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: CHA HEALTH SYSTEMS MEDICAL PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: CHA HEALTH SYSTEMS MEDICAL PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: CHA HEALTH SYSTEMS MEDICAL PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: CHA HEALTH SYSTEMS MEDICAL PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: CHA HEALTH SYSTEMS MEDICAL PLAN 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)Yes
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan funding arrangement – General assets of the sponsorYes
2009-02-01Plan benefit arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

VALUEOPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1298
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 62199 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1298
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1211
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1304
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1253
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1196
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3662111
Policy instance 3
Insurance contract or identification numberE3662111
Number of Individuals Covered242
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $181,138
Total amount of fees paid to insurance companyUSD $39,160
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $308,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91,143
Amount paid for insurance broker fees15389
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameRONNY ANN DAVID
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberUT708
Policy instance 2
Insurance contract or identification numberUT708
Number of Individuals Covered157
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $15,471
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $137,224
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,830
Insurance broker organization code?3
Insurance broker nameFIA INSURANCE SERVICES INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberUT708
Policy instance 1
Insurance contract or identification numberUT708
Number of Individuals Covered199
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $23,408
Total amount of fees paid to insurance companyUSD $2,234
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $180,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 2
Insurance contract or identification numberN/A
Number of Individuals Covered1266
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,086
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberUT708
Policy instance 2
Insurance contract or identification numberUT708
Number of Individuals Covered226
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $42,458
Total amount of fees paid to insurance companyUSD $2,916
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY PRODUCTS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $182,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,683
Amount paid for insurance broker fees1080
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameFIA INSURANCE SERVICES INC.
VALUEOPTIONS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberN/A
Policy instance 1
Insurance contract or identification numberN/A
Number of Individuals Covered1289
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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