401k Plan data: SPOKANE UNITED METHODIST HOMES plan

SPOKANE UNITED METHODIST HOMES 401k Plan overview

Plan Name	SPOKANE UNITED METHODIST HOMES
Plan identification number	501

SPOKANE UNITED METHODIST HOMES Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

SPOKANE UNITED METHODIST HOMES, INC has sponsored the creation of one or more 401k plans.

Company Name: SPOKANE UNITED METHODIST HOMES, INC

Employer identification number (EIN): 910715658

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about SPOKANE UNITED METHODIST HOMES, INC

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 1957-06-21

Company Identification Number: 328044638

Legal Registered Office Address: 2903 E 25TH AVE

SPOKANE
United States of America (USA)
992234992

More information about SPOKANE UNITED METHODIST HOMES, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SPOKANE UNITED METHODIST HOMES

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-02-01
501 2018-02-01
501 2017-02-01 JIM MAXWELL
501 2016-02-01 JIM MAXWELL
501 2015-02-01 JIM MAXWELL
501 2014-02-01 JIM MAXWELL
501 2013-02-01 JIM MAXWELL
501 2012-02-01 JIM MAXWELL JIM MAXWELL 2013-08-12
501 2011-02-01 JIM MAXWELL
501 2009-02-01 JAMES A. MAXWELL

Plan Statistics for SPOKANE UNITED METHODIST HOMES

401k plan membership statisitcs for SPOKANE UNITED METHODIST HOMES

Measure Date Value
2023: SPOKANE UNITED METHODIST HOMES 2023 401k membership
Total participants, beginning-of-year 2023-01-01 236
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 265
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 265
2022: SPOKANE UNITED METHODIST HOMES 2022 401k membership
Total participants, beginning-of-year 2022-01-01 230
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 236
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 236
2021: SPOKANE UNITED METHODIST HOMES 2021 401k membership
Total participants, beginning-of-year 2021-01-01 199
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 229
Number of retired or separated participants receiving benefits 2021-01-01 1
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 230
2020: SPOKANE UNITED METHODIST HOMES 2020 401k membership
Total participants, beginning-of-year 2020-01-01 222
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 199
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 199
2019: SPOKANE UNITED METHODIST HOMES 2019 401k membership
Total participants, beginning-of-year 2019-02-01 241
Total number of active participants reported on line 7a of the Form 5500 2019-02-01 222
Number of retired or separated participants receiving benefits 2019-02-01 0
Number of other retired or separated participants entitled to future benefits 2019-02-01 0
Total of all active and inactive participants 2019-02-01 222
2018: SPOKANE UNITED METHODIST HOMES 2018 401k membership
Total participants, beginning-of-year 2018-02-01 268
Total number of active participants reported on line 7a of the Form 5500 2018-02-01 241
Number of retired or separated participants receiving benefits 2018-02-01 0
Number of other retired or separated participants entitled to future benefits 2018-02-01 0
Total of all active and inactive participants 2018-02-01 241
2017: SPOKANE UNITED METHODIST HOMES 2017 401k membership
Total participants, beginning-of-year 2017-02-01 245
Total number of active participants reported on line 7a of the Form 5500 2017-02-01 268
Number of retired or separated participants receiving benefits 2017-02-01 0
Number of other retired or separated participants entitled to future benefits 2017-02-01 0
Total of all active and inactive participants 2017-02-01 268
2016: SPOKANE UNITED METHODIST HOMES 2016 401k membership
Total participants, beginning-of-year 2016-02-01 225
Total number of active participants reported on line 7a of the Form 5500 2016-02-01 245
Number of retired or separated participants receiving benefits 2016-02-01 0
Number of other retired or separated participants entitled to future benefits 2016-02-01 0
Total of all active and inactive participants 2016-02-01 245
2015: SPOKANE UNITED METHODIST HOMES 2015 401k membership
Total participants, beginning-of-year 2015-02-01 222
Total number of active participants reported on line 7a of the Form 5500 2015-02-01 225
Total of all active and inactive participants 2015-02-01 225
2014: SPOKANE UNITED METHODIST HOMES 2014 401k membership
Total participants, beginning-of-year 2014-02-01 226
Total number of active participants reported on line 7a of the Form 5500 2014-02-01 222
Total of all active and inactive participants 2014-02-01 222
2013: SPOKANE UNITED METHODIST HOMES 2013 401k membership
Total participants, beginning-of-year 2013-02-01 228
Total number of active participants reported on line 7a of the Form 5500 2013-02-01 226
Total of all active and inactive participants 2013-02-01 226
2012: SPOKANE UNITED METHODIST HOMES 2012 401k membership
Total participants, beginning-of-year 2012-02-01 211
Total number of active participants reported on line 7a of the Form 5500 2012-02-01 228
Total of all active and inactive participants 2012-02-01 228
2011: SPOKANE UNITED METHODIST HOMES 2011 401k membership
Total participants, beginning-of-year 2011-02-01 210
Total number of active participants reported on line 7a of the Form 5500 2011-02-01 211
Total of all active and inactive participants 2011-02-01 211
2009: SPOKANE UNITED METHODIST HOMES 2009 401k membership
Total participants, beginning-of-year 2009-02-01 201
Total number of active participants reported on line 7a of the Form 5500 2009-02-01 209
Number of retired or separated participants receiving benefits 2009-02-01 0
Number of other retired or separated participants entitled to future benefits 2009-02-01 0
Total of all active and inactive participants 2009-02-01 209

Measure	Date	Value
2023: SPOKANE UNITED METHODIST HOMES 2023 401k membership
Total participants, beginning-of-year	2023-01-01	236
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	265
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	265
2022: SPOKANE UNITED METHODIST HOMES 2022 401k membership
Total participants, beginning-of-year	2022-01-01	230
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	236
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	236
2021: SPOKANE UNITED METHODIST HOMES 2021 401k membership
Total participants, beginning-of-year	2021-01-01	199
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	229
Number of retired or separated participants receiving benefits	2021-01-01	1
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	230
2020: SPOKANE UNITED METHODIST HOMES 2020 401k membership
Total participants, beginning-of-year	2020-01-01	222
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	199
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	199
2019: SPOKANE UNITED METHODIST HOMES 2019 401k membership
Total participants, beginning-of-year	2019-02-01	241
Total number of active participants reported on line 7a of the Form 5500	2019-02-01	222
Number of retired or separated participants receiving benefits	2019-02-01	0
Number of other retired or separated participants entitled to future benefits	2019-02-01	0
Total of all active and inactive participants	2019-02-01	222
2018: SPOKANE UNITED METHODIST HOMES 2018 401k membership
Total participants, beginning-of-year	2018-02-01	268
Total number of active participants reported on line 7a of the Form 5500	2018-02-01	241
Number of retired or separated participants receiving benefits	2018-02-01	0
Number of other retired or separated participants entitled to future benefits	2018-02-01	0
Total of all active and inactive participants	2018-02-01	241
2017: SPOKANE UNITED METHODIST HOMES 2017 401k membership
Total participants, beginning-of-year	2017-02-01	245
Total number of active participants reported on line 7a of the Form 5500	2017-02-01	268
Number of retired or separated participants receiving benefits	2017-02-01	0
Number of other retired or separated participants entitled to future benefits	2017-02-01	0
Total of all active and inactive participants	2017-02-01	268
2016: SPOKANE UNITED METHODIST HOMES 2016 401k membership
Total participants, beginning-of-year	2016-02-01	225
Total number of active participants reported on line 7a of the Form 5500	2016-02-01	245
Number of retired or separated participants receiving benefits	2016-02-01	0
Number of other retired or separated participants entitled to future benefits	2016-02-01	0
Total of all active and inactive participants	2016-02-01	245
2015: SPOKANE UNITED METHODIST HOMES 2015 401k membership
Total participants, beginning-of-year	2015-02-01	222
Total number of active participants reported on line 7a of the Form 5500	2015-02-01	225
Total of all active and inactive participants	2015-02-01	225
2014: SPOKANE UNITED METHODIST HOMES 2014 401k membership
Total participants, beginning-of-year	2014-02-01	226
Total number of active participants reported on line 7a of the Form 5500	2014-02-01	222
Total of all active and inactive participants	2014-02-01	222
2013: SPOKANE UNITED METHODIST HOMES 2013 401k membership
Total participants, beginning-of-year	2013-02-01	228
Total number of active participants reported on line 7a of the Form 5500	2013-02-01	226
Total of all active and inactive participants	2013-02-01	226
2012: SPOKANE UNITED METHODIST HOMES 2012 401k membership
Total participants, beginning-of-year	2012-02-01	211
Total number of active participants reported on line 7a of the Form 5500	2012-02-01	228
Total of all active and inactive participants	2012-02-01	228
2011: SPOKANE UNITED METHODIST HOMES 2011 401k membership
Total participants, beginning-of-year	2011-02-01	210
Total number of active participants reported on line 7a of the Form 5500	2011-02-01	211
Total of all active and inactive participants	2011-02-01	211
2009: SPOKANE UNITED METHODIST HOMES 2009 401k membership
Total participants, beginning-of-year	2009-02-01	201
Total number of active participants reported on line 7a of the Form 5500	2009-02-01	209
Number of retired or separated participants receiving benefits	2009-02-01	0
Number of other retired or separated participants entitled to future benefits	2009-02-01	0
Total of all active and inactive participants	2009-02-01	209

Form 5500 Responses for SPOKANE UNITED METHODIST HOMES

2023: SPOKANE UNITED METHODIST HOMES 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: SPOKANE UNITED METHODIST HOMES 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: SPOKANE UNITED METHODIST HOMES 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: SPOKANE UNITED METHODIST HOMES 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: SPOKANE UNITED METHODIST HOMES 2019 form 5500 responses
2019-02-01	Type of plan entity	Single employer plan
2019-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-02-01	Plan funding arrangement – Insurance	Yes
2019-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-02-01	Plan benefit arrangement – Insurance	Yes
2019-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: SPOKANE UNITED METHODIST HOMES 2018 form 5500 responses
2018-02-01	Type of plan entity	Single employer plan
2018-02-01	Plan funding arrangement – Insurance	Yes
2018-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-02-01	Plan benefit arrangement – Insurance	Yes
2018-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: SPOKANE UNITED METHODIST HOMES 2017 form 5500 responses
2017-02-01	Type of plan entity	Single employer plan
2017-02-01	Plan funding arrangement – Insurance	Yes
2017-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-02-01	Plan benefit arrangement – Insurance	Yes
2017-02-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: SPOKANE UNITED METHODIST HOMES 2016 form 5500 responses
2016-02-01	Type of plan entity	Single employer plan
2016-02-01	Plan funding arrangement – Insurance	Yes
2016-02-01	Plan benefit arrangement – Insurance	Yes
2015: SPOKANE UNITED METHODIST HOMES 2015 form 5500 responses
2015-02-01	Type of plan entity	Single employer plan
2015-02-01	Submission has been amended	No
2015-02-01	This submission is the final filing	No
2015-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-02-01	Plan is a collectively bargained plan	No
2015-02-01	Plan funding arrangement – Insurance	Yes
2015-02-01	Plan benefit arrangement – Insurance	Yes
2014: SPOKANE UNITED METHODIST HOMES 2014 form 5500 responses
2014-02-01	Type of plan entity	Single employer plan
2014-02-01	Submission has been amended	No
2014-02-01	This submission is the final filing	No
2014-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-02-01	Plan is a collectively bargained plan	No
2014-02-01	Plan funding arrangement – Insurance	Yes
2014-02-01	Plan benefit arrangement – Insurance	Yes
2013: SPOKANE UNITED METHODIST HOMES 2013 form 5500 responses
2013-02-01	Type of plan entity	Single employer plan
2013-02-01	Submission has been amended	No
2013-02-01	This submission is the final filing	No
2013-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-02-01	Plan is a collectively bargained plan	No
2013-02-01	Plan funding arrangement – Insurance	Yes
2013-02-01	Plan benefit arrangement – Insurance	Yes
2012: SPOKANE UNITED METHODIST HOMES 2012 form 5500 responses
2012-02-01	Type of plan entity	Single employer plan
2012-02-01	Submission has been amended	No
2012-02-01	This submission is the final filing	No
2012-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-02-01	Plan is a collectively bargained plan	No
2012-02-01	Plan funding arrangement – Insurance	Yes
2012-02-01	Plan benefit arrangement – Insurance	Yes
2011: SPOKANE UNITED METHODIST HOMES 2011 form 5500 responses
2011-02-01	Type of plan entity	Single employer plan
2011-02-01	Submission has been amended	No
2011-02-01	This submission is the final filing	No
2011-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-02-01	Plan is a collectively bargained plan	No
2011-02-01	Plan funding arrangement – Insurance	Yes
2011-02-01	Plan benefit arrangement – Insurance	Yes
2009: SPOKANE UNITED METHODIST HOMES 2009 form 5500 responses
2009-02-01	Type of plan entity	Single employer plan
2009-02-01	Submission has been amended	No
2009-02-01	This submission is the final filing	No
2009-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-02-01	Plan is a collectively bargained plan	No
2009-02-01	Plan funding arrangement – Insurance	Yes
2009-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

00919

Policy instance

Insurance contract or identification number	00919
Number of Individuals Covered	235
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,738
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	19
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,416
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,852
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: 53031 )

Policy contract number

30094017

Policy instance

Insurance contract or identification number	30094017
Number of Individuals Covered	151
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,391
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,915
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	181
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $39,936
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $374,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CLI-SUM20243-03

Policy instance

Insurance contract or identification number	CLI-SUM20243-03
Number of Individuals Covered	163
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Welfare Benefit Premiums Paid to Carrier	USD $249,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	440
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BM8J

Policy instance

Insurance contract or identification number	GLTD0BM8J
Number of Individuals Covered	21
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,122
Total amount of fees paid to insurance company	USD $253
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BM8J

Policy instance

Insurance contract or identification number	GUDH0BM8J
Number of Individuals Covered	22
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $426
Total amount of fees paid to insurance company	USD $223
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $4,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BM8J

Policy instance

Insurance contract or identification number	GUDE0BM8J
Number of Individuals Covered	25
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $454
Total amount of fees paid to insurance company	USD $162
Other welfare benefits provided	VOLUNTARY CI
Welfare Benefit Premiums Paid to Carrier	USD $4,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BM8J

Policy instance

Insurance contract or identification number	GVTL0BM8J
Number of Individuals Covered	35
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,562
Total amount of fees paid to insurance company	USD $409
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $10,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BM8J

Policy instance

Insurance contract or identification number	GLUG0BM8J
Number of Individuals Covered	265
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,695
Total amount of fees paid to insurance company	USD $902
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $26,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

00919

Policy instance

Insurance contract or identification number	00919
Number of Individuals Covered	220
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,608
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,608
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30094017

Policy instance

Insurance contract or identification number	30094017
Number of Individuals Covered	144
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,358
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,358
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	171
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $50,400
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $505,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $50,400
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CLI-SUM20243-02

Policy instance

Insurance contract or identification number	CLI-SUM20243-02
Number of Individuals Covered	167
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Welfare Benefit Premiums Paid to Carrier	USD $292,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BM8J

Policy instance

Insurance contract or identification number	GLTD0BM8J
Number of Individuals Covered	22
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,085
Total amount of fees paid to insurance company	USD $291
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,085
Amount paid for insurance broker fees	291
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	390
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BM8J

Policy instance

Insurance contract or identification number	GLUG0BM8J
Number of Individuals Covered	236
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,578
Total amount of fees paid to insurance company	USD $894
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,578
Amount paid for insurance broker fees	894
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BM8J

Policy instance

Insurance contract or identification number	GVTL0BM8J
Number of Individuals Covered	40
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,754
Total amount of fees paid to insurance company	USD $416
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,754
Amount paid for insurance broker fees	416
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BM8J

Policy instance

Insurance contract or identification number	GUDE0BM8J
Number of Individuals Covered	28
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $463
Total amount of fees paid to insurance company	USD $486
Other welfare benefits provided	VOLUNTARY CI
Welfare Benefit Premiums Paid to Carrier	USD $4,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $463
Amount paid for insurance broker fees	486
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BM8J

Policy instance

Insurance contract or identification number	GUDH0BM8J
Number of Individuals Covered	27
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $636
Total amount of fees paid to insurance company	USD $241
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $636
Amount paid for insurance broker fees	241
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	17
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,584
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,584
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	182
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $40,824
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $458,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,824
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	14
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,480
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $42,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,480
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30094017

Policy instance

Insurance contract or identification number	30094017
Number of Individuals Covered	143
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,345
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,235
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,345
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

00919

Policy instance

Insurance contract or identification number	00919
Number of Individuals Covered	221
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,108
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,108
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CLI-SUM20243-01

Policy instance

Insurance contract or identification number	CLI-SUM20243-01
Number of Individuals Covered	169
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of fees paid to insurance company	USD $7,402
Welfare Benefit Premiums Paid to Carrier	USD $279,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	7402
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	400
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BM8J

Policy instance

Insurance contract or identification number	GLTD0BM8J
Number of Individuals Covered	23
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,247
Total amount of fees paid to insurance company	USD $269
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,247
Amount paid for insurance broker fees	269
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BM8J

Policy instance

Insurance contract or identification number	GLUG0BM8J
Number of Individuals Covered	229
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,554
Total amount of fees paid to insurance company	USD $853
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,554
Amount paid for insurance broker fees	853
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BM8J

Policy instance

Insurance contract or identification number	GVTL0BM8J
Number of Individuals Covered	47
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,784
Total amount of fees paid to insurance company	USD $616
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $11,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,784
Amount paid for insurance broker fees	616
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BM8J

Policy instance

Insurance contract or identification number	GUDE0BM8J
Number of Individuals Covered	37
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $547
Other welfare benefits provided	VOLUNTARY CI
Welfare Benefit Premiums Paid to Carrier	USD $5,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $547
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BM8J

Policy instance

Insurance contract or identification number	GUDH0BM8J
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $687
Other welfare benefits provided	VOLUNTARY ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $6,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $687
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )

Policy contract number

30094017

Policy instance

Insurance contract or identification number	30094017
Number of Individuals Covered	141
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,349
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,349
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	180
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $53,496
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $475,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $53,496
Insurance broker organization code?	3

COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )

Policy contract number

CLI-SUM20243-00

Policy instance

Insurance contract or identification number	CLI-SUM20243-00
Number of Individuals Covered	170
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Welfare Benefit Premiums Paid to Carrier	USD $296,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	400
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $6,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0BM8J

Policy instance

Insurance contract or identification number	GLTD0BM8J
Number of Individuals Covered	28
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,361
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,361
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0BM8J

Policy instance

Insurance contract or identification number	GLUG0BM8J
Number of Individuals Covered	225
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,538
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $25,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,538
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0BM8J

Policy instance

Insurance contract or identification number	GVTL0BM8J
Number of Individuals Covered	61
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,319
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOLUNTARY AD&D
Welfare Benefit Premiums Paid to Carrier	USD $15,463
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,319
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	14
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,536
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,536
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

00919

Policy instance

Insurance contract or identification number	00919
Number of Individuals Covered	224
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,766
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,766
Insurance broker organization code?	3

EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	400
Insurance policy start date	2019-06-01
Insurance policy end date	2019-12-31
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $3,500
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: 00000 )

Policy contract number

EMCL19100402003

Policy instance

Insurance contract or identification number	EMCL19100402003
Number of Individuals Covered	166
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $19,697
Welfare Benefit Premiums Paid to Carrier	USD $231,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,697
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	173
Insurance policy start date	2019-02-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $43,320
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $314,163
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,320
Insurance broker organization code?	3

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	222
Insurance policy start date	2019-02-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,916
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $29,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,916
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	16
Insurance policy start date	2019-02-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,320
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,018
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,320
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	190
Insurance policy start date	2019-02-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,897
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,897
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	202
Insurance policy start date	2018-02-01
Insurance policy end date	2019-01-31
Total amount of commissions paid to insurance broker	USD $3,304
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,304
Insurance broker organization code?	3

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	241
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,014
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,778
Insurance broker organization code?	3

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

8175800

Policy instance

Insurance contract or identification number	8175800
Number of Individuals Covered	19
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $5,568
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,568
Insurance broker organization code?	3

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4103000

Policy instance

Insurance contract or identification number	4103000
Number of Individuals Covered	178
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $47,302
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $306,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,904
Insurance broker organization code?	3

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EMCL18100402002

Policy instance

Insurance contract or identification number	EMCL18100402002
Number of Individuals Covered	185
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $17,807
Welfare Benefit Premiums Paid to Carrier	USD $209,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,807
Insurance broker organization code?	3

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	213
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $3,318
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,012
Insurance broker organization code?	3
Insurance broker name	BARRY C. FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6450200

Policy instance

Insurance contract or identification number	6450200
Number of Individuals Covered	24
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $4,390
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $186,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,390
Insurance broker organization code?	3
Insurance broker name	BARRY C. FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6450100

Policy instance

Insurance contract or identification number	6450100
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	268
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,565
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,565
Insurance broker organization code?	3
Insurance broker name	BARRY C. FOLSOM

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

4100200

Policy instance

Insurance contract or identification number	4100200
Number of Individuals Covered	177
Insurance policy start date	2016-07-01
Insurance policy end date	2017-06-30
Total amount of commissions paid to insurance broker	USD $26,273
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $957,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,273
Insurance broker organization code?	3
Insurance broker name	BARRY C FOLSOM

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

EMCL17100402001

Policy instance

Insurance contract or identification number	EMCL17100402001
Number of Individuals Covered	193
Insurance policy start date	2017-07-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $8,559
Total amount of fees paid to insurance company	USD $1,007
Welfare Benefit Premiums Paid to Carrier	USD $100,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,559
Amount paid for insurance broker fees	1007
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	170
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $2,538
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No
Commission paid to Insurance Broker	USD $2,538
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6450100

Policy instance

Insurance contract or identification number	6450100
Number of Individuals Covered	157
Insurance policy start date	2014-07-01
Insurance policy end date	2015-06-30
Total amount of commissions paid to insurance broker	USD $22,108
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $1,024,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,108
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	225
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,715
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $26,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,715
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949900

Policy instance

Insurance contract or identification number	6949900
Number of Individuals Covered	45
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $7,426
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $274,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,426
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	161
Insurance policy start date	2014-02-01
Insurance policy end date	2015-01-31
Total amount of commissions paid to insurance broker	USD $2,854
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No
Commission paid to Insurance Broker	USD $2,854
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	222
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,726
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $26,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,726
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949800

Policy instance

Insurance contract or identification number	6949800
Number of Individuals Covered	137
Insurance policy start date	2013-07-01
Insurance policy end date	2014-06-30
Total amount of commissions paid to insurance broker	USD $22,355
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $792,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,355
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	226
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $3,022
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $27,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,511
Insurance broker organization code?	3
Insurance broker name	MATTHEW J. WAGNER

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	185
Insurance policy start date	2013-02-01
Insurance policy end date	2014-01-31
Total amount of commissions paid to insurance broker	USD $2,995
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No
Commission paid to Insurance Broker	USD $2,995
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949800

Policy instance

Insurance contract or identification number	6949800
Number of Individuals Covered	138
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $22,658
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $756,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,658
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949900

Policy instance

Insurance contract or identification number	6949900
Number of Individuals Covered	47
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $7,652
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $276,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,652
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949800

Policy instance

Insurance contract or identification number	6949800
Number of Individuals Covered	131
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $21,232
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $708,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,232
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949900

Policy instance

Insurance contract or identification number	6949900
Number of Individuals Covered	44
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $7,566
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $256,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,566
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	179
Insurance policy start date	2012-02-01
Insurance policy end date	2013-01-31
Total amount of commissions paid to insurance broker	USD $4,935
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No
Commission paid to Insurance Broker	USD $4,935
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	228
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,684
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $26,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,342
Insurance broker organization code?	3
Insurance broker name	MATTHEW J. WAGNER

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	169
Insurance policy start date	2011-02-01
Insurance policy end date	2012-01-31
Total amount of commissions paid to insurance broker	USD $4,962
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949800

Policy instance

Insurance contract or identification number	6949800
Number of Individuals Covered	132
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $21,715
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $724,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	211
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,681
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $25,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949900

Policy instance

Insurance contract or identification number	6949900
Number of Individuals Covered	43
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $7,261
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $242,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 74341 )

Policy contract number

919

Policy instance

Insurance contract or identification number	919
Number of Individuals Covered	164
Insurance policy start date	2010-02-01
Insurance policy end date	2011-01-31
Total amount of commissions paid to insurance broker	USD $4,775
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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?	No
Commission paid to Insurance Broker	USD $4,775
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )

Policy contract number

WBT000137

Policy instance

Insurance contract or identification number	WBT000137
Number of Individuals Covered	210
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,733
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $26,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,733
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949800

Policy instance

Insurance contract or identification number	6949800
Number of Individuals Covered	123
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $18,725
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $616,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,725
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

6949900

Policy instance

Insurance contract or identification number	6949900
Number of Individuals Covered	45
Insurance policy start date	2009-07-01
Insurance policy end date	2010-06-30
Total amount of commissions paid to insurance broker	USD $7,452
Total amount of fees paid to insurance company	USD $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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 Carrier	USD $244,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,452
Insurance broker organization code?	3
Insurance broker name	BARRY FOLSOM

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Company Name:	SPOKANE UNITED METHODIST HOMES, INC
Employer identification number (EIN):	910715658
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	1957-06-21
Company Identification Number:	328044638
Legal Registered Office Address:	2903 E 25TH AVE SPOKANE United States of America (USA) 992234992