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MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 401k Plan overview

Plan NameMONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN
Plan identification number 502

MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN Benefits

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

401k Sponsoring company profile

MONTANA FOOD DISTRIBUTORS ASSOCIATION has sponsored the creation of one or more 401k plans.

Company Name:MONTANA FOOD DISTRIBUTORS ASSOCIATION
Employer identification number (EIN):810171144
NAIC Classification:445110
NAIC Description:Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022019-01-01
5022018-01-01
5022017-01-01RON RAMSBACHER
5022017-01-01RON RAMSBACHER
5022016-01-01MITCH BRADLEY MITCH BRADLEY2017-11-20

Plan Statistics for MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN

401k plan membership statisitcs for MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN

Measure Date Value
2019: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01411
Total number of active participants reported on line 7a of the Form 55002019-01-01411
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01411
2018: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01584
Total number of active participants reported on line 7a of the Form 55002018-01-01411
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01411
2017: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01512
Total number of active participants reported on line 7a of the Form 55002017-01-01387
Number of retired or separated participants receiving benefits2017-01-012
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01389
2016: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01159
Total number of active participants reported on line 7a of the Form 55002016-01-01511
Number of retired or separated participants receiving benefits2016-01-011
Total of all active and inactive participants2016-01-01512
Total participants2016-01-01512
Number of employers contributing to the scheme2016-01-014

Financial Data on MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN

Measure Date Value
2019 : MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$576,006
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$576,006
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$383,880
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$383,880
Total income from all sources (including contributions)2019-12-31$2,751,708
Total income from all sources (including contributions)2019-12-31$2,751,708
Total loss/gain on sale of assets2019-12-31$0
Total loss/gain on sale of assets2019-12-31$0
Total of all expenses incurred2019-12-31$3,106,305
Total of all expenses incurred2019-12-31$3,106,305
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$2,323,290
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$2,323,290
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$2,751,237
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$2,751,237
Value of total assets at end of year2019-12-31$655,214
Value of total assets at end of year2019-12-31$655,214
Value of total assets at beginning of year2019-12-31$817,685
Value of total assets at beginning of year2019-12-31$817,685
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$783,015
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$783,015
Total interest from all sources2019-12-31$471
Total interest from all sources2019-12-31$471
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Was this plan covered by a fidelity bond2019-12-31Yes
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$500,000
Value of fidelity bond cover2019-12-31$500,000
If this is an individual account plan, was there a blackout period2019-12-31No
If this is an individual account plan, was there a blackout period2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$91,568
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$91,568
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$164,273
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$164,273
Administrative expenses (other) incurred2019-12-31$783,015
Administrative expenses (other) incurred2019-12-31$783,015
Liabilities. Value of operating payables at end of year2019-12-31$53,962
Liabilities. Value of operating payables at end of year2019-12-31$53,962
Liabilities. Value of operating payables at beginning of year2019-12-31$50,219
Liabilities. Value of operating payables at beginning of year2019-12-31$50,219
Total non interest bearing cash at end of year2019-12-31$563,646
Total non interest bearing cash at end of year2019-12-31$563,646
Total non interest bearing cash at beginning of year2019-12-31$653,412
Total non interest bearing cash at beginning of year2019-12-31$653,412
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$-354,597
Value of net income/loss2019-12-31$-354,597
Value of net assets at end of year (total assets less liabilities)2019-12-31$79,208
Value of net assets at end of year (total assets less liabilities)2019-12-31$79,208
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$433,805
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$433,805
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Interest earned on other investments2019-12-31$471
Interest earned on other investments2019-12-31$471
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$2,323,290
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$2,323,290
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$2,751,237
Contributions received in cash from employer2019-12-31$2,751,237
Liabilities. Value of benefit claims payable at end of year2019-12-31$522,044
Liabilities. Value of benefit claims payable at end of year2019-12-31$522,044
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$333,661
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$333,661
Did the plan have assets held for investment2019-12-31No
Did the plan have assets held for investment2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31WIPFLI LLP
Accountancy firm name2019-12-31WIPFLI LLP
Accountancy firm EIN2019-12-31390758449
Accountancy firm EIN2019-12-31390758449
2018 : MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets2018-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$383,880
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$384,642
Total income from all sources (including contributions)2018-12-31$3,082,752
Total loss/gain on sale of assets2018-12-31$0
Total of all expenses incurred2018-12-31$2,788,371
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$1,913,553
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$3,082,449
Value of total assets at end of year2018-12-31$817,685
Value of total assets at beginning of year2018-12-31$524,066
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$874,818
Total interest from all sources2018-12-31$303
Total dividends received (eg from common stock, registered investment company shares)2018-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$500,000
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Value of other receiveables (less allowance for doubtful accounts) at end of year2018-12-31$164,273
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2018-12-31$256,849
Administrative expenses (other) incurred2018-12-31$874,818
Liabilities. Value of operating payables at end of year2018-12-31$50,219
Liabilities. Value of operating payables at beginning of year2018-12-31$31,320
Total non interest bearing cash at end of year2018-12-31$653,412
Total non interest bearing cash at beginning of year2018-12-31$267,217
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$294,381
Value of net assets at end of year (total assets less liabilities)2018-12-31$433,805
Value of net assets at beginning of year (total assets less liabilities)2018-12-31$139,424
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Interest earned on other investments2018-12-31$303
Expenses. Payments to insurance carriers foe the provision of benefits2018-12-31$1,913,553
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contributions received in cash from employer2018-12-31$3,082,449
Liabilities. Value of benefit claims payable at end of year2018-12-31$333,661
Liabilities. Value of benefit claims payable at beginning of year2018-12-31$353,322
Did the plan have assets held for investment2018-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31No
Opinion of an independent qualified public accountant for this plan2018-12-31Unqualified
Accountancy firm name2018-12-31WIPFLI LLP
Accountancy firm EIN2018-12-31390758449
2017 : MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets2017-12-31$0
Total transfer of assets to this plan2017-12-31$250,000
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$384,642
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$544,255
Total income from all sources (including contributions)2017-12-31$2,944,883
Total loss/gain on sale of assets2017-12-31$0
Total of all expenses incurred2017-12-31$2,962,069
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2017-12-31$1,920,460
Total contributions o plan (from employers,participants, others, non cash contrinutions)2017-12-31$2,944,776
Value of total assets at end of year2017-12-31$524,066
Value of total assets at beginning of year2017-12-31$450,865
Total of administrative expenses incurred including professional, contract, advisory and management fees2017-12-31$1,041,609
Total interest from all sources2017-12-31$107
Total dividends received (eg from common stock, registered investment company shares)2017-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31Yes
Value of fidelity bond cover2017-12-31$500,000
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Contributions received from participants2017-12-31$2,780,327
Income. Received or receivable in cash from other sources (including rollovers)2017-12-31$164,449
Value of other receiveables (less allowance for doubtful accounts) at end of year2017-12-31$348,249
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2017-12-31$286,037
Administrative expenses (other) incurred2017-12-31$1,041,609
Liabilities. Value of operating payables at end of year2017-12-31$119,385
Liabilities. Value of operating payables at beginning of year2017-12-31$183,553
Total non interest bearing cash at end of year2017-12-31$175,817
Total non interest bearing cash at beginning of year2017-12-31$164,828
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net income/loss2017-12-31$-17,186
Value of net assets at end of year (total assets less liabilities)2017-12-31$139,424
Value of net assets at beginning of year (total assets less liabilities)2017-12-31$-93,390
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Interest earned on other investments2017-12-31$107
Expenses. Payments to insurance carriers foe the provision of benefits2017-12-31$1,920,460
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Contributions received in cash from employer2017-12-31$2,944,776
Liabilities. Value of benefit claims payable at end of year2017-12-31$265,257
Liabilities. Value of benefit claims payable at beginning of year2017-12-31$360,702
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2017-12-31No
Opinion of an independent qualified public accountant for this plan2017-12-31Unqualified
Accountancy firm name2017-12-31WIPFLI LLP
Accountancy firm EIN2017-12-31390758449
2016 : MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets2016-12-31$0
Total transfer of assets to this plan2016-12-31$350,967
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$544,255
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$0
Total income from all sources (including contributions)2016-12-31$2,823,870
Total loss/gain on sale of assets2016-12-31$0
Total of all expenses incurred2016-12-31$3,268,227
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2016-12-31$2,554,472
Total contributions o plan (from employers,participants, others, non cash contrinutions)2016-12-31$2,823,870
Value of total assets at end of year2016-12-31$450,865
Value of total assets at beginning of year2016-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2016-12-31$713,755
Total interest from all sources2016-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2016-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-12-31No
Administrative expenses professional fees incurred2016-12-31$265,288
Was this plan covered by a fidelity bond2016-12-31Yes
Value of fidelity bond cover2016-12-31$500,000
If this is an individual account plan, was there a blackout period2016-12-31No
Were there any nonexempt tranactions with any party-in-interest2016-12-31No
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)2016-12-31$2,030,291
Value of other receiveables (less allowance for doubtful accounts) at end of year2016-12-31$286,037
Administrative expenses (other) incurred2016-12-31$240,783
Liabilities. Value of operating payables at end of year2016-12-31$183,553
Total non interest bearing cash at end of year2016-12-31$164,828
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Value of net income/loss2016-12-31$-444,357
Value of net assets at end of year (total assets less liabilities)2016-12-31$-93,390
Value of net assets at beginning of year (total assets less liabilities)2016-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-12-31No
Were any leases to which the plan was party in default or uncollectible2016-12-31No
Expenses. Payments to insurance carriers foe the provision of benefits2016-12-31$524,181
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-12-31No
Was there a failure to transmit to the plan any participant contributions2016-12-31No
Has the plan failed to provide any benefit when due under the plan2016-12-31No
Contributions received in cash from employer2016-12-31$2,823,870
Contract administrator fees2016-12-31$207,684
Liabilities. Value of benefit claims payable at end of year2016-12-31$360,702
Did the plan have assets held for investment2016-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2016-12-31No
Opinion of an independent qualified public accountant for this plan2016-12-31Unqualified
Accountancy firm name2016-12-31WIPFLI LLP
Accountancy firm EIN2016-12-31390758449

Form 5500 Responses for MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN

2019: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entityMulitple employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes
2018: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entityMulitple employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – TrustYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement - TrustYes
2017: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entityMulitple employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – TrustYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement - TrustYes
2016: MONTANA FOOD DISTRIBUTORS ASSOCIATION GROUP BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entityMulitple employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – TrustYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number2007540
Policy instance 1
Insurance contract or identification number2007540
Number of Individuals Covered399
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
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 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 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 $401,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number2007540
Policy instance 1
Insurance contract or identification number2007540
Number of Individuals Covered399
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
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 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 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 $447,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )
Policy contract numberERLL16101134001
Policy instance 1
Insurance contract or identification numberERLL16101134001
Number of Individuals Covered0
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
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 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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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