MUCKLESHOOT INDIAN TRIBE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2023: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 3,045 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 3,229 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 8 |
| 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 | 3,237 |
| Number of employers contributing to the scheme | 2023-01-01 | 0 |
| 2022: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 2,880 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 3,041 |
| 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 | 3,041 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 2,500 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 2,880 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| 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 | 2,880 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 3,000 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 2,491 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 9 |
| Total of all active and inactive participants | 2020-01-01 | 2,500 |
| Total participants | 2020-01-01 | 2,500 |
| 2019: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 2,970 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 2,989 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 10 |
| Total of all active and inactive participants | 2019-01-01 | 2,999 |
| 2018: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 2,902 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 2,911 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 12 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 2,923 |
| 2017: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 2,750 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 2,862 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 2,879 |
| 2016: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 2,655 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 2,718 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 2,727 |
| 2015: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 2,528 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 2,573 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 2,579 |
| 2014: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 2,421 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 2,474 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 2,483 |
| 2013: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 2,361 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 2,353 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 2,359 |
| 2012: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 2,449 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 2,370 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 2,379 |
| 2011: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 2,507 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 2,445 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 16 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 2,461 |
| Total participants | 2011-01-01 | 2,461 |
| 2010: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 2,609 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 2,514 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 2,528 |
| 2009: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 2,563 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 2,604 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 26 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 2,630 |
| 2023: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 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: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 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: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 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: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 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: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | Yes |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | Yes |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | Yes |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: MUCKLESHOOT INDIAN TRIBE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 4 |
| Insurance contract or identification number | 614220 | | Number of Individuals Covered | 3229 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $39,308 | | Total amount of fees paid to insurance company | USD $34,188 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,471,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 427683 |
| Policy instance | 3 |
| Insurance contract or identification number | 427683 | | Number of Individuals Covered | 522 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $3,942 | | Total amount of fees paid to insurance company | USD $3,942 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $131,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 |
| Policy instance | 2 |
| Insurance contract or identification number | WA127 | | Number of Individuals Covered | 880 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 3452 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $110,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 3154 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $98,006 | | 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 | 30043798 |
| Policy instance | 2 |
| Insurance contract or identification number | 30043798 | | Number of Individuals Covered | 3063 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $200,477 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 |
| Policy instance | 3 |
| Insurance contract or identification number | WA127 | | Number of Individuals Covered | 898 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 427683 |
| Policy instance | 4 |
| Insurance contract or identification number | 427683 | | Number of Individuals Covered | 553 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,234 | | Total amount of fees paid to insurance company | USD $2,008 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $114,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 5 |
| Insurance contract or identification number | 614220 | | Number of Individuals Covered | 2998 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $62,484 | | Total amount of fees paid to insurance company | USD $29,131 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,314,479 | | 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 | 30043798 |
| Policy instance | 2 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 00 |
| Policy instance | 1 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 5 |
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 427683 |
| Policy instance | 4 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0693572 |
| Policy instance | 2 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 4 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30043798 |
| Policy instance | 5 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 11537945 |
| Policy instance | 6 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427681 |
| Policy instance | 7 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427682 |
| Policy instance | 8 |
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 427683 |
| Policy instance | 9 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | |
| Policy instance | 1 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | |
| Policy instance | 4 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 3 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30043798 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 1 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0008460363 |
| Policy instance | 6 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 7 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0011537945 |
| Policy instance | 8 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0693572 |
| Policy instance | 9 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 |
| Policy instance | 10 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 11 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30043798 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 1 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | N/A |
| Policy instance | 5 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 / Z1936 |
| Policy instance | 6 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0008460363 |
| Policy instance | 7 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0693572 |
| Policy instance | 8 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0011537945 |
| Policy instance | 9 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 614220 |
| Policy instance | 10 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 10 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0693572 |
| Policy instance | 9 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 0008460363 |
| Policy instance | 8 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 / Z1936 |
| Policy instance | 7 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | N/A |
| Policy instance | 6 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30043798 |
| Policy instance | 5 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 1 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | N/A |
| Policy instance | 6 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30043798 |
| Policy instance | 5 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 3 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 1 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 / Z1936 |
| Policy instance | 7 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 7 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | N/A |
| Policy instance | 1 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 ) |
| Policy contract number | 30043798 |
| Policy instance | 2 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | WA127 / Z1936 |
| Policy instance | 3 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 5 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 6 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 3 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 0 |
| Policy instance | 2 |
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 75069 ) |
| Policy contract number | Z1936 |
| Policy instance | 3 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 0 |
| Policy instance | 1 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 2 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK966613 |
| Policy instance | 4 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK963483 |
| Policy instance | 5 |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX965010 |
| Policy instance | 1 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | Z1936 |
| Policy instance | 5 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 6 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 0 |
| Policy instance | 1 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 549488 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 543094 |
| Policy instance | 2 |
| WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 75069 ) |
| Policy contract number | Z1936 |
| Policy instance | 4 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 549488 |
| Policy instance | 2 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 543094 |
| Policy instance | 4 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 5 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | Z1936 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 543094 |
| Policy instance | 3 |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460363 |
| Policy instance | 2 |
| WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 ) |
| Policy contract number | Z1936 |
| Policy instance | 5 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 549488 |
| Policy instance | 1 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | N/A |
| Policy instance | 4 |
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | 031616 |
| Policy instance | 3 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 543094 |
| Policy instance | 2 |
| WELLSPRING FAMILY SERVICES, EAP (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | 0 |
| Policy instance | 1 |
