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| Plan Name | QOBALT HEALTH PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | PROSERO |
| Employer identification number (EIN): | 582480035 |
| NAIC Classification: | 493100 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2023-10-01 | CELESTE LOCKE | 2024-08-28 | ||
| 501 | 2022-10-01 | CELESTE LOCKE | 2024-06-05 |
| 2023: QOBALT HEALTH PLAN 2023 form 5500 responses | ||
|---|---|---|
| 2023-10-01 | Type of plan entity | Single employer plan |
| 2023-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2023-10-01 | Plan funding arrangement – Insurance | Yes |
| 2023-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: QOBALT HEALTH PLAN 2022 form 5500 responses | ||
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | First time form 5500 has been submitted | Yes |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | 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 | 636761 | ||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) | |||||||||||||||||||||||
| Policy contract number | 954692 | ||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) | |||||||||||||||||||||||
| Policy contract number | 636761 | ||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) | |||||||||||||||||||||||
| Policy contract number | 954692 | ||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||
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