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| Plan Name | QBE OPTIMA INSURANCE COMPANY HEALTH PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | QBE OPTIMA INSURANCE COMPANY |
| Employer identification number (EIN): | 660648224 |
| NAIC Classification: | 524210 |
| NAIC Description: | Insurance Agencies and Brokerages |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2017-09-01 | ROSA IVONNE OTERO | ROSA IVONNE OTERO | 2018-12-17 | |
| 501 | 2017-09-01 | ROSA IVONNE OTERO | 2018-12-17 | ||
| 501 | 2012-09-01 | ROSA IVONNE OTERO | ROSA IVONNE OTERO | 2014-07-08 |
| Measure | Date | Value |
|---|---|---|
| 2017: QBE OPTIMA INSURANCE COMPANY HEALTH PLAN 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-09-01 | 101 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 103 |
| Total of all active and inactive participants | 2017-09-01 | 103 |
| Total participants | 2017-09-01 | 103 |
| 2012: QBE OPTIMA INSURANCE COMPANY HEALTH PLAN 2012 401k membership | ||
| Total participants, beginning-of-year | 2012-09-01 | 122 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 123 |
| Total of all active and inactive participants | 2012-09-01 | 123 |
| Total participants | 2012-09-01 | 123 |
| 2017: QBE OPTIMA INSURANCE COMPANY HEALTH PLAN 2017 form 5500 responses | ||
|---|---|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | Yes |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: QBE OPTIMA INSURANCE COMPANY HEALTH PLAN 2012 form 5500 responses | ||
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | First time form 5500 has been submitted | Yes |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SGM606548 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SOK604633 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SGD604438 |
| Policy instance | 3 |
| PAN AMERICAN LIFE INSURANCE GROUP (National Association of Insurance Commissioners NAIC id number: 67539 ) | |
| Policy contract number | 88626 |
| Policy instance | 4 |
| PAN AMERICAN LIFE INSURANCE GROUP (National Association of Insurance Commissioners NAIC id number: 67539 ) | |
| Policy contract number | 88626 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SGD604438 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SOK604633 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) | |
| Policy contract number | SGM606548 |
| Policy instance | 4 |
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