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CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 401k Plan overview

Plan NameCLEANPART INTERNATIONAL, INC. MEDICAL PLAN
Plan identification number 501

CLEANPART INTERNATIONAL, INC. MEDICAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Vision
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CLEANPART USA, INC. has sponsored the creation of one or more 401k plans.

Company Name:CLEANPART USA, INC.
Employer identification number (EIN):861107725
NAIC Classification:334410

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLEANPART INTERNATIONAL, INC. MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01LESLIE ARNO2023-10-27
5012021-04-01LESLIE ARNO2022-10-13
5012020-04-01LESLIE ARNO2021-09-13
5012019-04-01LESLIE ARNO2020-09-11
5012018-04-01LESLIE ARNO2019-09-25
5012017-04-01
5012016-04-01
5012015-04-01LESLIE ARNO
5012011-04-01LESLIE ARNO

Plan Statistics for CLEANPART INTERNATIONAL, INC. MEDICAL PLAN

401k plan membership statisitcs for CLEANPART INTERNATIONAL, INC. MEDICAL PLAN

Measure Date Value
2022: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01109
Total number of active participants reported on line 7a of the Form 55002022-04-01109
Number of retired or separated participants receiving benefits2022-04-010
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01109
Number of employers contributing to the scheme2022-04-010
2021: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01107
Total number of active participants reported on line 7a of the Form 55002021-04-01109
Number of retired or separated participants receiving benefits2021-04-010
Number of other retired or separated participants entitled to future benefits2021-04-010
Total of all active and inactive participants2021-04-01109
Number of employers contributing to the scheme2021-04-010
2020: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01126
Total number of active participants reported on line 7a of the Form 55002020-04-01107
Number of retired or separated participants receiving benefits2020-04-010
Number of other retired or separated participants entitled to future benefits2020-04-010
Total of all active and inactive participants2020-04-01107
Number of employers contributing to the scheme2020-04-010
2019: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01123
Total number of active participants reported on line 7a of the Form 55002019-04-01123
Number of retired or separated participants receiving benefits2019-04-010
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01123
Number of employers contributing to the scheme2019-04-010
2018: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01123
Total number of active participants reported on line 7a of the Form 55002018-04-01120
Number of retired or separated participants receiving benefits2018-04-011
Number of other retired or separated participants entitled to future benefits2018-04-011
Total of all active and inactive participants2018-04-01122
Number of employers contributing to the scheme2018-04-010
2017: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01100
Total number of active participants reported on line 7a of the Form 55002017-04-01114
Number of retired or separated participants receiving benefits2017-04-012
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01116
2016: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01103
Total number of active participants reported on line 7a of the Form 55002016-04-01105
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01105
2015: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01113
Total number of active participants reported on line 7a of the Form 55002015-04-01103
Number of retired or separated participants receiving benefits2015-04-010
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01103
2011: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-0179
Total number of active participants reported on line 7a of the Form 55002011-04-0195
Number of retired or separated participants receiving benefits2011-04-010
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-0195

Form 5500 Responses for CLEANPART INTERNATIONAL, INC. MEDICAL PLAN

2022: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – InsuranceYes
2021: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – InsuranceYes
2020: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – InsuranceYes
2019: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – InsuranceYes
2018: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – InsuranceYes
2017: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – InsuranceYes
2016: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2011: CLEANPART INTERNATIONAL, INC. MEDICAL PLAN 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01First time form 5500 has been submittedYes
2011-04-01Submission has been amendedYes
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number10-044930
Policy instance 2
Insurance contract or identification number10-044930
Number of Individuals Covered237
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $12,609
Total amount of fees paid to insurance companyUSD $4,193
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $126,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,609
Amount paid for insurance broker fees4193
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered193
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $98,376
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,737,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees98376
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-044930
Policy instance 2
Insurance contract or identification number010-044930
Number of Individuals Covered235
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $2,046
Total amount of fees paid to insurance companyUSD $4,471
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,046
Amount paid for insurance broker fees4471
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered202
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $81,656
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,685,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,656
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-044930
Policy instance 2
Insurance contract or identification number010-044930
Number of Individuals Covered246
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $14,892
Total amount of fees paid to insurance companyUSD $6,705
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $148,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,892
Amount paid for insurance broker fees6705
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered106
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $91,635
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,618,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees91635
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number010-044930
Policy instance 2
Insurance contract or identification number010-044930
Number of Individuals Covered264
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $16,062
Total amount of fees paid to insurance companyUSD $6,413
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $160,617
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,062
Amount paid for insurance broker fees6413
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered207
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $84,949
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,164,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees84949
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT BONUS
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered210
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $73,876
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,417,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees73876
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number01004493000002
Policy instance 2
Insurance contract or identification number01004493000002
Number of Individuals Covered272
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $2,212
Total amount of fees paid to insurance companyUSD $4,576
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,212
Amount paid for insurance broker fees4576
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )
Policy contract number01004493000002
Policy instance 2
Insurance contract or identification number01004493000002
Number of Individuals Covered239
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $1,992
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,992
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number911082
Policy instance 1
Insurance contract or identification number911082
Number of Individuals Covered202
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $57,844
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,108,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees57844
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number492725
Policy instance 2
Insurance contract or identification number492725
Number of Individuals Covered81
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $26,170
Are there contracts with allocated funds for individual policies?No
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 $418,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees26170
Additional information about fees paid to insurance broker2014/2015 PPP ENGAGEMENT CREDIT DIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameMASH AND MCLENNAN AGENCY, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12253071
Policy instance 3
Insurance contract or identification number12253071
Number of Individuals Covered93
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $834
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 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 $11,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $834
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY, LLC
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 )
Policy contract number492725HNO
Policy instance 1
Insurance contract or identification number492725HNO
Number of Individuals Covered103
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $30,636
Are there contracts with allocated funds for individual policies?No
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 $577,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees30636
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number492725
Policy instance 2
Insurance contract or identification number492725
Number of Individuals Covered45
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $7,438
Are there contracts with allocated funds for individual policies?No
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 $159,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 )
Policy contract numberUS436677
Policy instance 1
Insurance contract or identification numberUS436677
Number of Individuals Covered172
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $22,532
Are there contracts with allocated funds for individual policies?No
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 $475,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12253071
Policy instance 4
Insurance contract or identification number12253071
Number of Individuals Covered94
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $737
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 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 $9,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number154619
Policy instance 3
Insurance contract or identification number154619
Number of Individuals Covered95
Insurance policy start date2011-03-01
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $3,272
Total amount of fees paid to insurance companyUSD $654
Are there contracts with allocated funds for individual policies?No
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 $34,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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