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GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN
Plan identification number 501

GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

GOLDEN QUEEN MINING COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name:GOLDEN QUEEN MINING COMPANY, LLC
Employer identification number (EIN):471904841
NAIC Classification:212200
NAIC Description: Metal Ore Mining

Additional information about GOLDEN QUEEN MINING COMPANY, LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 201425310169

More information about GOLDEN QUEEN MINING COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01LATASHA MARSHALL2023-05-18 LATASHA MARSHALL2023-05-18
5012021-01-01DENISE TALVITIE2022-06-20 DENISE TALVITIE2022-06-20
5012020-01-01DENISE TALVITIE2021-07-27 DENISE TALVITIE2021-07-27
5012019-01-01DENISE TALVITIE2020-11-16 DENISE TALVITIE2020-11-16
5012019-01-01DENISE TALVITIE2020-11-13 DENISE TALVITIE2020-11-13
5012018-01-01
5012017-01-01

Plan Statistics for GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN

401k plan membership statisitcs for GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN

Measure Date Value
2022: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01240
Total number of active participants reported on line 7a of the Form 55002022-01-01230
Total of all active and inactive participants2022-01-01230
2021: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01225
Total number of active participants reported on line 7a of the Form 55002021-01-01240
Total of all active and inactive participants2021-01-01240
2020: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01248
Total number of active participants reported on line 7a of the Form 55002020-01-01253
Total of all active and inactive participants2020-01-01253
2019: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01200
Total number of active participants reported on line 7a of the Form 55002019-01-01230
Total of all active and inactive participants2019-01-01230
2018: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01185
Total number of active participants reported on line 7a of the Form 55002018-01-01181
Total of all active and inactive participants2018-01-01181
2017: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01185
Total number of active participants reported on line 7a of the Form 55002017-01-01185
Total of all active and inactive participants2017-01-01185
Total participants2017-01-01185

Form 5500 Responses for GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN

2022: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 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: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 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: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 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: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 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: GOLDEN QUEEN MINING COMPANY, LLC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30079850
Policy instance 5
Insurance contract or identification number30079850
Number of Individuals Covered215
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,149
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,149
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5391960
Policy instance 4
Insurance contract or identification number5391960
Number of Individuals Covered230
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,770
Total amount of fees paid to insurance companyUSD $60
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $49,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,770
Amount paid for insurance broker fees60
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19894
Policy instance 3
Insurance contract or identification number19894
Number of Individuals Covered536
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $22,338
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $223,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,338
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233823
Policy instance 2
Insurance contract or identification number233823
Number of Individuals Covered284
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $633,551
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,402,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $633,551
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )
Policy contract numberW8000025
Policy instance 1
Insurance contract or identification numberW8000025
Number of Individuals Covered209
Total amount of commissions paid to insurance brokerUSD $1,209,180
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedMEDICAL/DRUG
Welfare Benefit Premiums Paid to CarrierUSD $63,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,209,180
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910403
Policy instance 1
Insurance contract or identification number910403
Number of Individuals Covered251
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $70,182
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,534,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70,182
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233823
Policy instance 2
Insurance contract or identification number233823
Number of Individuals Covered326
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $75,675
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,300,004
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,675
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19894
Policy instance 3
Insurance contract or identification number19894
Number of Individuals Covered624
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $19,699
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $188,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,699
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010246986
Policy instance 4
Insurance contract or identification number000010246986
Number of Individuals Covered260
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,757
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $107,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,757
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30079850
Policy instance 5
Insurance contract or identification number30079850
Number of Individuals Covered239
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,251
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,251
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30079850
Policy instance 5
Insurance contract or identification number30079850
Number of Individuals Covered236
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,697
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $51,393
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,697
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010246986
Policy instance 4
Insurance contract or identification number000010246986
Number of Individuals Covered249
Total amount of commissions paid to insurance brokerUSD $11,298
Total amount of fees paid to insurance companyUSD $124
Other welfare benefits providedAD&D/LIFE
Welfare Benefit Premiums Paid to CarrierUSD $112,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,298
Amount paid for insurance broker fees124
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19894
Policy instance 3
Insurance contract or identification number19894
Number of Individuals Covered634
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $19,305
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $193,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,305
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233823
Policy instance 2
Insurance contract or identification number233823
Number of Individuals Covered307
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $58,583
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,296,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,583
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910403
Policy instance 1
Insurance contract or identification number910403
Number of Individuals Covered276
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $71,975
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,312,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71,975
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30079850
Policy instance 5
Insurance contract or identification number30079850
Number of Individuals Covered233
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,213
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $49,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,213
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010246986
Policy instance 4
Insurance contract or identification number000010246986
Number of Individuals Covered243
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $9,266
Total amount of fees paid to insurance companyUSD $3,875
Other welfare benefits providedAD&D/LIFE
Welfare Benefit Premiums Paid to CarrierUSD $90,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,266
Amount paid for insurance broker fees3875
Insurance broker organization code?3
DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number19894
Policy instance 3
Insurance contract or identification number19894
Number of Individuals Covered635
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $17,754
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $177,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,754
Amount paid for insurance broker fees0
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233823
Policy instance 2
Insurance contract or identification number233823
Number of Individuals Covered303
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $55,174
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,084,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,174
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910403
Policy instance 1
Insurance contract or identification number910403
Number of Individuals Covered278
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $69,685
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,393,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69,685
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910403
Policy instance 1
Insurance contract or identification number910403
Number of Individuals Covered297
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $66,175
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,447,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $66,175
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number920478-000,-099
Policy instance 2
Insurance contract or identification number920478-000,-099
Number of Individuals Covered545
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $16,528
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $164,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,528
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 157328
Policy instance 3
Insurance contract or identification numberGL 157328
Number of Individuals Covered181
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,649
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $112,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,649
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233823
Policy instance 4
Insurance contract or identification number233823
Number of Individuals Covered190
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $40,300
Total amount of fees paid to insurance companyUSD $7,500
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $935,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,300
Amount paid for insurance broker fees7500
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30079850
Policy instance 5
Insurance contract or identification number30079850
Number of Individuals Covered196
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,292
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,292
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 157328
Policy instance 3
Insurance contract or identification numberGL 157328
Number of Individuals Covered173
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,312
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $76,196
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,312
Insurance broker organization code?3
Insurance broker nameWALTER MORTENSEN INSURANCE
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number920478- &-099
Policy instance 2
Insurance contract or identification number920478- &-099
Number of Individuals Covered431
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $15,271
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $152,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,271
Insurance broker organization code?3
Insurance broker nameGUARANTY CALIFORNIA INSURANCE SERVI
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910403
Policy instance 1
Insurance contract or identification number910403
Number of Individuals Covered515
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $86,454
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,599,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,454
Insurance broker organization code?3
Insurance broker nameINSURICA CA INSURANCE SERVICES INC

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