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WESTERN INTEGRATED GROUP MEDICAL PLAN 401k Plan overview

Plan NameWESTERN INTEGRATED GROUP MEDICAL PLAN
Plan identification number 501

WESTERN INTEGRATED GROUP MEDICAL PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

WESTERN INTEGRATED TECHNOLOGIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:WESTERN INTEGRATED TECHNOLOGIES, INC.
Employer identification number (EIN):910847960
NAIC Classification:423800

Additional information about WESTERN INTEGRATED TECHNOLOGIES, INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 1969-08-11
Company Identification Number: 179023947
Legal Registered Office Address: 7651 S 190TH ST

KENT
United States of America (USA)
980321029

More information about WESTERN INTEGRATED TECHNOLOGIES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WESTERN INTEGRATED GROUP MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01STEVE SCHWASNICK2023-04-28
5012020-10-01TIM O'HARA2022-04-21
5012019-10-01STEPHANIE EKEREN2021-04-20
5012018-10-01TIM O'HARA2020-05-06
5012017-10-01
5012016-10-01MICHELLE KENNEY MICHELLE KENNEY2018-04-19
5012015-10-01MICHELLE KENNEY
5012015-01-01MICHELLE KENNEY
5012014-01-01MICHELLE KENNEY
5012013-01-01MICHELLE KENNEY

Plan Statistics for WESTERN INTEGRATED GROUP MEDICAL PLAN

401k plan membership statisitcs for WESTERN INTEGRATED GROUP MEDICAL PLAN

Measure Date Value
2021: WESTERN INTEGRATED GROUP MEDICAL PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01105
Total number of active participants reported on line 7a of the Form 55002021-10-01145
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01145
Number of employers contributing to the scheme2021-10-010
2020: WESTERN INTEGRATED GROUP MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01113
Total number of active participants reported on line 7a of the Form 55002020-10-01105
Number of retired or separated participants receiving benefits2020-10-010
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01105
Number of employers contributing to the scheme2020-10-010
2019: WESTERN INTEGRATED GROUP MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01119
Total number of active participants reported on line 7a of the Form 55002019-10-01113
Number of retired or separated participants receiving benefits2019-10-010
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01113
Number of employers contributing to the scheme2019-10-010
2018: WESTERN INTEGRATED GROUP MEDICAL PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01129
Total number of active participants reported on line 7a of the Form 55002018-10-01119
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-01119
Number of employers contributing to the scheme2018-10-010
2017: WESTERN INTEGRATED GROUP MEDICAL PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01123
Total number of active participants reported on line 7a of the Form 55002017-10-01126
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-013
Total of all active and inactive participants2017-10-01129
Number of employers contributing to the scheme2017-10-010
2016: WESTERN INTEGRATED GROUP MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01100
Total number of active participants reported on line 7a of the Form 55002016-10-01120
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-013
Total of all active and inactive participants2016-10-01123
2015: WESTERN INTEGRATED GROUP MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01127
Total number of active participants reported on line 7a of the Form 55002015-10-0192
Number of retired or separated participants receiving benefits2015-10-013
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-0195
Total participants, beginning-of-year2015-01-01112
Total number of active participants reported on line 7a of the Form 55002015-01-01117
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01117
2014: WESTERN INTEGRATED GROUP MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01112
Total number of active participants reported on line 7a of the Form 55002014-01-01119
Number of retired or separated participants receiving benefits2014-01-010
Total of all active and inactive participants2014-01-01119
2013: WESTERN INTEGRATED GROUP MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01140
Total number of active participants reported on line 7a of the Form 55002013-01-01133
Number of retired or separated participants receiving benefits2013-01-011
Total of all active and inactive participants2013-01-01134

Form 5500 Responses for WESTERN INTEGRATED GROUP MEDICAL PLAN

2021: WESTERN INTEGRATED GROUP MEDICAL PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: WESTERN INTEGRATED GROUP MEDICAL PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – InsuranceYes
2019: WESTERN INTEGRATED GROUP MEDICAL PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – InsuranceYes
2018: WESTERN INTEGRATED GROUP MEDICAL PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: WESTERN INTEGRATED GROUP MEDICAL PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: WESTERN INTEGRATED GROUP MEDICAL PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: WESTERN INTEGRATED GROUP MEDICAL PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: WESTERN INTEGRATED GROUP MEDICAL PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: WESTERN INTEGRATED GROUP MEDICAL PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01First time form 5500 has been submittedYes
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number886042G
Policy instance 2
Insurance contract or identification number886042G
Number of Individuals Covered145
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $3,558
Total amount of fees paid to insurance companyUSD $3,032
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $35,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,558
Amount paid for insurance broker fees542
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4016031
Policy instance 1
Insurance contract or identification number4016031
Number of Individuals Covered205
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $48,931
Total amount of fees paid to insurance companyUSD $13,971
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,223,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,931
Amount paid for insurance broker fees13971
Additional information about fees paid to insurance brokerPREFERRED PRODUCER PROGRAM
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number886042G
Policy instance 2
Insurance contract or identification number886042G
Number of Individuals Covered105
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $2,813
Total amount of fees paid to insurance companyUSD $2,573
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $28,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,813
Amount paid for insurance broker fees605
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4016031
Policy instance 1
Insurance contract or identification number4016031
Number of Individuals Covered195
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $38,098
Total amount of fees paid to insurance companyUSD $10,464
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $952,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,098
Amount paid for insurance broker fees10464
Additional information about fees paid to insurance brokerPREFERRED PRODUCER PROGRAM
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number886042G
Policy instance 2
Insurance contract or identification number886042G
Number of Individuals Covered113
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $3,416
Total amount of fees paid to insurance companyUSD $2,661
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $34,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,416
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4016031
Policy instance 1
Insurance contract or identification number4016031
Number of Individuals Covered194
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $40,090
Total amount of fees paid to insurance companyUSD $7,767
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,002,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,090
Amount paid for insurance broker fees7767
Additional information about fees paid to insurance brokerPREFERRED PRODUCER PROGRAM
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number886042G
Policy instance 2
Insurance contract or identification number886042G
Number of Individuals Covered119
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $2,984
Total amount of fees paid to insurance companyUSD $3,816
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $29,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,984
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )
Policy contract number4016031
Policy instance 1
Insurance contract or identification number4016031
Number of Individuals Covered196
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $42,232
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $844,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,232
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number517201
Policy instance 2
Insurance contract or identification number517201
Number of Individuals Covered126
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $4,853
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $105,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10019174
Policy instance 1
Insurance contract or identification number10019174
Number of Individuals Covered195
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $51,431
Total amount of fees paid to insurance companyUSD $2,140
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,027,703
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00517201
Policy instance 2
Insurance contract or identification number00517201
Number of Individuals Covered118
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $3,434
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $75,347
Commission paid to Insurance BrokerUSD $3,434
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10019174
Policy instance 1
Insurance contract or identification number10019174
Number of Individuals Covered95
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $35,674
Total amount of fees paid to insurance companyUSD $5,950
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $774,962
Commission paid to Insurance BrokerUSD $35,674
Amount paid for insurance broker fees5950
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWA300445
Policy instance 3
Insurance contract or identification numberWA300445
Number of Individuals Covered118
Insurance policy start date2015-01-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,848
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number100000048
Policy instance 2
Insurance contract or identification number100000048
Number of Individuals Covered118
Insurance policy start date2015-01-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $43,220
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $864,401
Commission paid to Insurance BrokerUSD $43,220
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )
Policy contract number00075
Policy instance 1
Insurance contract or identification number00075
Number of Individuals Covered118
Insurance policy start date2015-01-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $3,627
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $72,534
Commission paid to Insurance BrokerUSD $3,627
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05981655
Policy instance 2
Insurance contract or identification numberKM05981655
Number of Individuals Covered282
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,712
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $75,141
Commission paid to Insurance BrokerUSD $3,712
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number65400020
Policy instance 1
Insurance contract or identification number65400020
Number of Individuals Covered113
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $33,909
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $675,613
Commission paid to Insurance BrokerUSD $33,909
Insurance broker organization code?3
Insurance broker nameR.L. EVANS COMPANY, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05981655
Policy instance 2
Insurance contract or identification numberKM05981655
Number of Individuals Covered227
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,677
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $73,870
Commission paid to Insurance BrokerUSD $3,677
Insurance broker organization code?3
Insurance broker nameRL EVANS COMPANY, INC.
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number65400020
Policy instance 1
Insurance contract or identification number65400020
Number of Individuals Covered145
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $30,345
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $608,920
Commission paid to Insurance BrokerUSD $30,345
Insurance broker organization code?3
Insurance broker nameRL EVANS COMPANY, INC.

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