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HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 401k Plan overview

Plan NameHOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN
Plan identification number 501

HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN Benefits

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

401k Sponsoring company profile

HOSPICE OF THE PIEDMONT, INC. has sponsored the creation of one or more 401k plans.

Company Name:HOSPICE OF THE PIEDMONT, INC.
Employer identification number (EIN):521205921
NAIC Classification:621399
NAIC Description:Offices of All Other Miscellaneous Health Practitioners

Additional information about HOSPICE OF THE PIEDMONT, INC.

Jurisdiction of Incorporation: Virginia Secretary of State
Incorporation Date: 1980-09-16
Company Identification Number: 0209649
Legal Registered Office Address: 675 PETER JEFFERSON PKWY

CHARLOTTESVILLE
United States of America (USA)
22911

More information about HOSPICE OF THE PIEDMONT, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-08-01
5012021-08-01
5012020-08-01
5012019-08-01
5012018-08-01
5012017-08-01MARIELLEN HAGY
5012016-08-01MARIELLEN HAGY

Plan Statistics for HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN

401k plan membership statisitcs for HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN

Measure Date Value
2022: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2022 401k membership
Total participants, beginning-of-year2022-08-01125
Total number of active participants reported on line 7a of the Form 55002022-08-01120
Number of retired or separated participants receiving benefits2022-08-011
Number of other retired or separated participants entitled to future benefits2022-08-010
Total of all active and inactive participants2022-08-01121
2021: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-08-01146
Total number of active participants reported on line 7a of the Form 55002021-08-01127
Number of retired or separated participants receiving benefits2021-08-011
Number of other retired or separated participants entitled to future benefits2021-08-010
Total of all active and inactive participants2021-08-01128
2020: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01149
Total number of active participants reported on line 7a of the Form 55002020-08-01167
Number of retired or separated participants receiving benefits2020-08-011
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-01168
2019: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01138
Total number of active participants reported on line 7a of the Form 55002019-08-01160
Number of retired or separated participants receiving benefits2019-08-012
Number of other retired or separated participants entitled to future benefits2019-08-010
Total of all active and inactive participants2019-08-01162
2018: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01138
Total number of active participants reported on line 7a of the Form 55002018-08-01138
Number of retired or separated participants receiving benefits2018-08-010
Number of other retired or separated participants entitled to future benefits2018-08-010
Total of all active and inactive participants2018-08-01138
2017: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01125
Total number of active participants reported on line 7a of the Form 55002017-08-01133
Number of retired or separated participants receiving benefits2017-08-010
Number of other retired or separated participants entitled to future benefits2017-08-010
Total of all active and inactive participants2017-08-01133
2016: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01125
Total number of active participants reported on line 7a of the Form 55002016-08-01125
Number of retired or separated participants receiving benefits2016-08-010
Number of other retired or separated participants entitled to future benefits2016-08-010
Total of all active and inactive participants2016-08-01125

Form 5500 Responses for HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN

2022: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2022 form 5500 responses
2022-08-01Type of plan entitySingle employer plan
2022-08-01Submission has been amendedNo
2022-08-01This submission is the final filingNo
2022-08-01This return/report is a short plan year return/report (less than 12 months)No
2022-08-01Plan is a collectively bargained planNo
2022-08-01Plan funding arrangement – InsuranceYes
2022-08-01Plan benefit arrangement – InsuranceYes
2021: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Submission has been amendedNo
2021-08-01This submission is the final filingNo
2021-08-01This return/report is a short plan year return/report (less than 12 months)No
2021-08-01Plan is a collectively bargained planNo
2021-08-01Plan funding arrangement – InsuranceYes
2021-08-01Plan benefit arrangement – InsuranceYes
2020: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)No
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Submission has been amendedNo
2018-08-01This submission is the final filingNo
2018-08-01This return/report is a short plan year return/report (less than 12 months)No
2018-08-01Plan is a collectively bargained planNo
2018-08-01Plan funding arrangement – InsuranceYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Submission has been amendedNo
2017-08-01This submission is the final filingNo
2017-08-01This return/report is a short plan year return/report (less than 12 months)No
2017-08-01Plan is a collectively bargained planNo
2017-08-01Plan funding arrangement – InsuranceYes
2017-08-01Plan benefit arrangement – InsuranceYes
2016: HOSPICE OF THE PIEDMONT MEDICAL & DENTAL PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01First time form 5500 has been submittedYes
2016-08-01Submission has been amendedNo
2016-08-01This submission is the final filingNo
2016-08-01This return/report is a short plan year return/report (less than 12 months)No
2016-08-01Plan is a collectively bargained planNo
2016-08-01Plan funding arrangement – InsuranceYes
2016-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract numberDD7010
Policy instance 1
Insurance contract or identification numberDD7010
Number of Individuals Covered232
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $41,478
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $1,757,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,935
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract numberDD7010
Policy instance 1
Insurance contract or identification numberDD7010
Number of Individuals Covered210
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $40,449
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $2,061,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,449
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract numberDD7010
Policy instance 1
Insurance contract or identification numberDD7010
Number of Individuals Covered248
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $43,194
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $2,166,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,180
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number72783
Policy instance 5
Insurance contract or identification number72783
Number of Individuals Covered50
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $599
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $389,144
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $599
Insurance broker organization code?3
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number65293
Policy instance 4
Insurance contract or identification number65293
Number of Individuals Covered7
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $107
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $70,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $107
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number3222
Policy instance 3
Insurance contract or identification number3222
Number of Individuals Covered101
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,165
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $727,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,165
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number16349
Policy instance 2
Insurance contract or identification number16349
Number of Individuals Covered77
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $852
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $485,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $852
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract numberDD7010
Policy instance 1
Insurance contract or identification numberDD7010
Number of Individuals Covered239
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,966
Total amount of fees paid to insurance companyUSD $2,459
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $112,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,246
Amount paid for insurance broker fees2459
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number72783
Policy instance 5
Insurance contract or identification number72783
Number of Individuals Covered64
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $5,205
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $346,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,205
Insurance broker organization code?3
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number65293
Policy instance 4
Insurance contract or identification number65293
Number of Individuals Covered9
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,159
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $77,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,159
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number3222
Policy instance 3
Insurance contract or identification number3222
Number of Individuals Covered134
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $12,037
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $802,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,037
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number16349
Policy instance 2
Insurance contract or identification number16349
Number of Individuals Covered36
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,690
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $244,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,690
Insurance broker organization code?3
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number851502
Policy instance 1
Insurance contract or identification number851502
Number of Individuals Covered126
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $3,924
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $78,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,924
Insurance broker organization code?3
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number72783
Policy instance 5
Insurance contract or identification number72783
Number of Individuals Covered33
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $5,927
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $197,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OHIC-OOA IND (National Association of Insurance Commissioners NAIC id number: 70715 )
Policy contract number65293
Policy instance 4
Insurance contract or identification number65293
Number of Individuals Covered6
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $1,396
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $46,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number3222
Policy instance 3
Insurance contract or identification number3222
Number of Individuals Covered143
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $23,129
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $770,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OHP MANDATED POS-HMO (National Association of Insurance Commissioners NAIC id number: 95281 )
Policy contract number16349
Policy instance 2
Insurance contract or identification number16349
Number of Individuals Covered49
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $8,157
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
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
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 $273,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number851502
Policy instance 1
Insurance contract or identification number851502
Number of Individuals Covered127
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $3,766
Total amount of fees paid to insurance companyUSD $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 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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $75,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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