401k Plan data: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN plan

AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 401k Plan overview

Plan Name	AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN
Plan identification number	520

AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision

401k Sponsoring company profile

AMERICAN BEHAVIORAL HEALTH SYSTEMS has sponsored the creation of one or more 401k plans.

Company Name: AMERICAN BEHAVIORAL HEALTH SYSTEMS

Employer identification number (EIN): 911824793

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
520 2022-07-01 TONY PRENTICE 2023-12-12 TONY PRENTICE 2023-12-12
520 2021-07-01 TONY PRENTICE 2022-10-19 TONY PRENTICE 2022-10-19
520 2020-07-01 TONY PRENTICE TONY PRENTICE
520 2020-03-01 TONY PRENTICE TONY PRENTICE
520 2019-03-01 TIFFANY STRETCH TIFFANY STRETCH
520 2018-03-01 TIFFANY STRETCH 2019-12-16 TIFFANY STRETCH 2019-12-16
520 2017-03-01
520 2017-03-01
520 2016-03-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
520	2022-07-01	TONY PRENTICE	2023-12-12	TONY PRENTICE	2023-12-12
520	2021-07-01	TONY PRENTICE	2022-10-19	TONY PRENTICE	2022-10-19
520	2020-07-01	TONY PRENTICE		TONY PRENTICE
520	2020-03-01	TONY PRENTICE		TONY PRENTICE
520	2019-03-01	TIFFANY STRETCH		TIFFANY STRETCH
520	2018-03-01	TIFFANY STRETCH	2019-12-16	TIFFANY STRETCH	2019-12-16
520	2017-03-01
520	2017-03-01
520	2016-03-01

Plan Statistics for AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN

401k plan membership statisitcs for AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN

Measure Date Value
2022: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 280
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 247
Total of all active and inactive participants 2022-07-01 247
2021: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 315
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 280
Total of all active and inactive participants 2021-07-01 280
2020: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 279
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 315
Total of all active and inactive participants 2020-07-01 315
Total participants, beginning-of-year 2020-03-01 485
Total number of active participants reported on line 7a of the Form 5500 2020-03-01 279
Total of all active and inactive participants 2020-03-01 279
2019: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year 2019-03-01 369
Total number of active participants reported on line 7a of the Form 5500 2019-03-01 485
Total of all active and inactive participants 2019-03-01 485
2018: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year 2018-03-01 202
Total number of active participants reported on line 7a of the Form 5500 2018-03-01 369
Total of all active and inactive participants 2018-03-01 369
2017: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-03-01 159
Total number of active participants reported on line 7a of the Form 5500 2017-03-01 202
Total of all active and inactive participants 2017-03-01 202
2016: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 65
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 159
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 159

Measure	Date	Value
2022: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	280
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	247
Total of all active and inactive participants	2022-07-01	247
2021: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	315
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	280
Total of all active and inactive participants	2021-07-01	280
2020: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	279
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	315
Total of all active and inactive participants	2020-07-01	315
Total participants, beginning-of-year	2020-03-01	485
Total number of active participants reported on line 7a of the Form 5500	2020-03-01	279
Total of all active and inactive participants	2020-03-01	279
2019: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year	2019-03-01	369
Total number of active participants reported on line 7a of the Form 5500	2019-03-01	485
Total of all active and inactive participants	2019-03-01	485
2018: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year	2018-03-01	202
Total number of active participants reported on line 7a of the Form 5500	2018-03-01	369
Total of all active and inactive participants	2018-03-01	369
2017: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-03-01	159
Total number of active participants reported on line 7a of the Form 5500	2017-03-01	202
Total of all active and inactive participants	2017-03-01	202
2016: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	65
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	159
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	159

Form 5500 Responses for AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN

2022: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020-03-01	Type of plan entity	Single employer plan
2020-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2020-03-01	Plan funding arrangement – Insurance	Yes
2020-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-03-01	Plan benefit arrangement – Insurance	Yes
2020-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2017 form 5500 responses
2017-03-01	Type of plan entity	Single employer plan
2017-03-01	Submission has been amended	Yes
2017-03-01	Plan funding arrangement – Insurance	Yes
2017-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-03-01	Plan benefit arrangement – Insurance	Yes
2017-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: AMERICAN BEHAVIORAL HEALTH SYSTEMS, INC. PREMIUM ONLY PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	First time form 5500 has been submitted	Yes
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	15
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $6,250
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,250
Insurance broker organization code?	3

WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )

Policy contract number

WA707

Policy instance

Insurance contract or identification number	WA707
Number of Individuals Covered	153
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $3,735
Total amount of fees paid to insurance company	USD $0
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 $3,735

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	247
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $1,274
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,274
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

760266

Policy instance

Insurance contract or identification number	760266
Number of Individuals Covered	131
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $4,501
Total amount of fees paid to insurance company	USD $0
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 $4,501
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	169
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $39,489
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,363,101
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,489
Insurance broker organization code?	1

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	86
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $18,573
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $636,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,573
Insurance broker organization code?	3

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	110
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $21,414
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $736,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,414
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	152
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $31,411
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,016,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,411
Insurance broker organization code?	3

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	239
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $1,222
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,222
Insurance broker organization code?	3

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	15
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,247
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $70,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,247
Insurance broker organization code?	3

WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )

Policy contract number

WA707

Policy instance

Insurance contract or identification number	WA707
Number of Individuals Covered	165
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,238
Total amount of fees paid to insurance company	USD $0
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 $4,238

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

760266

Policy instance

Insurance contract or identification number	760266
Number of Individuals Covered	113
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,700
Total amount of fees paid to insurance company	USD $0
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 $4,700

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	137
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $23,913
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $812,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,913
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	123
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $24,724
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $811,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,724
Insurance broker organization code?	3

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

Policy contract number

05942

Policy instance

Insurance contract or identification number	05942
Number of Individuals Covered	242
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $7,067
Total amount of fees paid to insurance company	USD $0
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 $7,067
Insurance broker organization code?	3

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	258
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,250
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,250
Insurance broker organization code?	3

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	13
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,989
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $83,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,989
Insurance broker organization code?	3

WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )

Policy contract number

WA707

Policy instance

Insurance contract or identification number	WA707
Number of Individuals Covered	102
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $2,460
Total amount of fees paid to insurance company	USD $0
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 $2,460

WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )

Policy contract number

WA707

Policy instance

Insurance contract or identification number	WA707
Number of Individuals Covered	98
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $778
Total amount of fees paid to insurance company	USD $0
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 $778

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	10
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,242
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,242
Insurance broker organization code?	3

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	251
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
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 $7,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Insurance broker organization code?	3

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

Policy contract number

05942

Policy instance

Insurance contract or identification number	05942
Number of Individuals Covered	230
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,149
Total amount of fees paid to insurance company	USD $0
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 $2,149
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	89
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $6,504
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $222,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,504
Insurance broker organization code?	3

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	189
Insurance policy start date	2020-03-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $12,544
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $397,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,544
Insurance broker organization code?	3

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	183
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $37,148
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,166,954
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,148
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	83
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $20,291
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $621,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,291
Insurance broker organization code?	3

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

Policy contract number

5942

Policy instance

Insurance contract or identification number	5942
Number of Individuals Covered	223
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $6,284
Total amount of fees paid to insurance company	USD $0
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 $6,284
Insurance broker organization code?	3

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	250
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $1,211
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,211
Insurance broker organization code?	3

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	10
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $3,039
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $51,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,039
Insurance broker organization code?	3

WILLAMETTE DENTAL OF WASHINGTON, INC. (National Association of Insurance Commissioners NAIC id number: 47050 )

Policy contract number

WA707

Policy instance

Insurance contract or identification number	WA707
Number of Individuals Covered	106
Insurance policy start date	2019-03-01
Insurance policy end date	2020-02-29
Total amount of commissions paid to insurance broker	USD $2,537
Total amount of fees paid to insurance company	USD $0
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 $2,537
Insurance broker organization code?	3

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	190
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $42,192
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,219,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,192
Insurance broker organization code?	3

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

Policy contract number

8169300

Policy instance

Insurance contract or identification number	8169300
Number of Individuals Covered	50
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $8,358
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $383,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,358
Insurance broker organization code?	3

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

Policy contract number

5942

Policy instance

Insurance contract or identification number	5942
Number of Individuals Covered	302
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $7,569
Total amount of fees paid to insurance company	USD $0
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 $7,569
Insurance broker organization code?	3

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	237
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
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 $20,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	10
Insurance policy start date	2018-03-01
Insurance policy end date	2019-02-28
Total amount of commissions paid to insurance broker	USD $3,813
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $62,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,813
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0011427939

Policy instance

Insurance contract or identification number	0011427939
Number of Individuals Covered	188
Insurance policy start date	2018-03-01
Insurance policy end date	2019-03-01
Total amount of commissions paid to insurance broker	USD $1,635
Total amount of fees paid to insurance company	USD $542
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $48,746
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,624
Amount paid for insurance broker fees	542
Insurance broker organization code?	3

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

Policy contract number

6496700

Policy instance

Insurance contract or identification number	6496700
Number of Individuals Covered	27
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $5,481
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $243,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,481
Insurance broker organization code?	3
Insurance broker name	PAYNEWEST INSURANCE INC

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

Policy contract number

5942

Policy instance

Insurance contract or identification number	5942
Number of Individuals Covered	252
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $6,200
Total amount of fees paid to insurance company	USD $0
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 $6,200
Insurance broker organization code?	3
Insurance broker name	PAYNEWEST INSURANCE INC

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

Policy contract number

30056703

Policy instance

Insurance contract or identification number	30056703
Number of Individuals Covered	191
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $846
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $846
Insurance broker organization code?	3
Insurance broker name	PAYNEWEST INSURANCE INC

PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 )

Policy contract number

4006350

Policy instance

Insurance contract or identification number	4006350
Number of Individuals Covered	10
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $2,992
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,992
Insurance broker organization code?	3
Insurance broker name	CONNEXION INSURANCE SOLUTIONS INC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

0011427939

Policy instance

Insurance contract or identification number	0011427939
Number of Individuals Covered	152
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-01
Total amount of commissions paid to insurance broker	USD $1,748
Total amount of fees paid to insurance company	USD $481
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,649
Amount paid for insurance broker fees	481
Insurance broker organization code?	3
Insurance broker name	UNUM BEN ADMIN

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

879683

Policy instance

Insurance contract or identification number	879683
Number of Individuals Covered	165
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-01
Total amount of commissions paid to insurance broker	USD $3,366
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,366
Insurance broker organization code?	3
Insurance broker name	PAYNEWEST INSURANCE INC

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

Policy contract number

4053000

Policy instance

Insurance contract or identification number	4053000
Number of Individuals Covered	186
Insurance policy start date	2017-03-01
Insurance policy end date	2018-02-28
Total amount of commissions paid to insurance broker	USD $39,594
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,017,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39,594
Insurance broker organization code?	3
Insurance broker name	PAYNEWEST INSURANCE INC

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Company Name:	AMERICAN BEHAVIORAL HEALTH SYSTEMS
Employer identification number (EIN):	911824793
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities