AD HOC LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AD HOC LLC HEALTH AND WELFARE PLAN
| 2023: AD HOC LLC HEALTH AND WELFARE PLAN 2023 form 5500 responses |
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| 2023-06-01 | Type of plan entity | Single employer plan |
| 2023-06-01 | Submission has been amended | No |
| 2023-06-01 | This submission is the final filing | No |
| 2023-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2023-06-01 | Plan is a collectively bargained plan | No |
| 2023-06-01 | Plan funding arrangement – Insurance | Yes |
| 2023-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: AD HOC LLC HEALTH AND WELFARE PLAN 2022 form 5500 responses |
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| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: AD HOC LLC HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: AD HOC LLC HEALTH AND WELFARE PLAN 2020 form 5500 responses |
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| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: AD HOC LLC HEALTH AND WELFARE PLAN 2019 form 5500 responses |
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| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: AD HOC LLC HEALTH AND WELFARE PLAN 2018 form 5500 responses |
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| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | First time form 5500 has been submitted | Yes |
| 2018-06-01 | Submission has been amended | Yes |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | AI110662 |
| Policy instance | 5 |
| Insurance contract or identification number | AI110662 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2023-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL INJURY, VOLUNTARY CRITICAL ILLNESS, HOSPITAL CARE | | 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 $40,574 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000B765 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B765 | | Number of Individuals Covered | 540 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $13,372 | | Total amount of fees paid to insurance company | USD $12,014 | | 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 | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $223,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 121524 |
| Policy instance | 3 |
| Insurance contract or identification number | 121524 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2023-12-31 | | 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 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 $5,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759421 |
| Policy instance | 2 |
| Insurance contract or identification number | 759421 | | Number of Individuals Covered | 464 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $15,406 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $180,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3345031 |
| Policy instance | 1 |
| Insurance contract or identification number | 3345031 | | Number of Individuals Covered | 440 | | Insurance policy start date | 2023-06-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $121,568 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $3,187,043 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3345031 |
| Policy instance | 1 |
| Insurance contract or identification number | 3345031 | | Number of Individuals Covered | 443 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $148,885 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,609,813 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759421 |
| Policy instance | 2 |
| Insurance contract or identification number | 759421 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $38,481 | | Total amount of fees paid to insurance company | USD $3,786 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 ) |
| Policy contract number | 121524 |
| Policy instance | 3 |
| Insurance contract or identification number | 121524 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B765 |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0B765 | | Number of Individuals Covered | 547 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $21,060 | | Total amount of fees paid to insurance company | USD $55,109 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $452,152 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B765 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759421 |
| Policy instance | 2 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 1ZET |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B765 |
| Policy instance | 3 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 759421 |
| Policy instance | 2 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 1ZET |
| Policy instance | 1 |
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 921576-000 |
| Policy instance | 2 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10172151001 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B765 |
| Policy instance | 4 |
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 1ZET |
| Policy instance | 1 |
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 1ZET |
| Policy instance | 1 |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10172151001 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B765 |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B765 |
| Policy instance | 5 |
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 921576 ET AL |
| Policy instance | 2 |
