DELTA SAND & GRAVEL CO. has sponsored the creation of one or more 401k plans.
Additional information about DELTA SAND & GRAVEL CO.
Submission information for form 5500 for 401k plan DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY
401k plan membership statisitcs for DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY
| Measure | Date | Value |
|---|
| 2022: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 109 |
| 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 | 109 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 114 |
| 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 | 114 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 108 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 108 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 119 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 119 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2018: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 113 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| 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 | 113 |
| Number of employers contributing to the scheme | 2018-01-01 | 0 |
| 2017: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 112 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| 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 | 112 |
| 2016: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 110 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| 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 | 110 |
| 2010: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 77 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 77 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 0 |
| 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 | 77 |
| 2009: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 77 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 77 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| 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 | 77 |
| 2022: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 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: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 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: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 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 benefit arrangement – Insurance | Yes |
| 2010: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | Yes |
| 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 benefit arrangement – Insurance | Yes |
| 2009: DELTA SAND & GRAVEL CO. EMPLOYEE WELFARE PLAN LIFE AND DISABILITY 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 benefit arrangement – Insurance | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 1D035989 |
| Policy instance | 4 |
| Insurance contract or identification number | 1D035989 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,613 | | Total amount of fees paid to insurance company | USD $2,041 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $87,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,613 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| WELLWORKS FOR YOU (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12219 |
| Policy instance | 3 |
| Insurance contract or identification number | 12219 | | Number of Individuals Covered | 109 | | 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 | WELLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $1,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GRP00005544 |
| Policy instance | 2 |
| Insurance contract or identification number | GRP00005544 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $346 | | Total amount of fees paid to insurance company | USD $230 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $346 | | Amount paid for insurance broker fees | 230 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0043008 |
| Policy instance | 1 |
| Insurance contract or identification number | G0043008 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $25,277 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,377,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,277 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WELLWORKS FOR YOU (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12219 |
| Policy instance | 3 |
| Insurance contract or identification number | 12219 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | WELLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $1,000 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GRP00005544 |
| Policy instance | 2 |
| Insurance contract or identification number | GRP00005544 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $958 | | Total amount of fees paid to insurance company | USD $230 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $958 | | Amount paid for insurance broker fees | 230 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 117389 |
| Policy instance | 1 |
| Insurance contract or identification number | 117389 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $25,046 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,257,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,046 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 1D035989 |
| Policy instance | 4 |
| Insurance contract or identification number | 1D035989 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-30 | | Total amount of commissions paid to insurance broker | USD $4,492 | | Total amount of fees paid to insurance company | USD $789 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $85,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,492 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 1D035989 |
| Policy instance | 4 |
| Insurance contract or identification number | 1D035989 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-30 | | Total amount of commissions paid to insurance broker | USD $4,576 | | Total amount of fees paid to insurance company | USD $3,442 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $87,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,576 | | Amount paid for insurance broker fees | 3442 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | WELLNESS | | 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? | Yes |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GRP00005544 |
| Policy instance | 2 |
| Insurance contract or identification number | GRP00005544 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $223 | | Total amount of fees paid to insurance company | USD $159 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,437 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $223 | | Amount paid for insurance broker fees | 159 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 117389 |
| Policy instance | 1 |
| Insurance contract or identification number | 117389 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $29,381 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,356,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,381 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10236835 |
| Policy instance | 2 |
| Insurance contract or identification number | 10236835 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-30 | | Total amount of commissions paid to insurance broker | USD $5,011 | | Total amount of fees paid to insurance company | USD $4,065 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $95,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,011 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 117389 |
| Policy instance | 1 |
| Insurance contract or identification number | 117389 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $25,624 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,393,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,624 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 1D035989 |
| Policy instance | 2 |
| Insurance contract or identification number | 1D035989 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-30 | | Total amount of commissions paid to insurance broker | USD $4,750 | | Total amount of fees paid to insurance company | USD $6,760 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $90,596 | | 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 | | Amount paid for insurance broker fees | 6760 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 117389 |
| Policy instance | 1 |
| Insurance contract or identification number | 117389 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $23,608 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,181,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,608 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
| Policy contract number | GR0038081 |
| Policy instance | 2 |
| Insurance contract or identification number | GR0038081 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,832 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $94,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,832 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | KIBBLE AND PRENTICE HOLDING COMPANY |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10013748 |
| Policy instance | 1 |
| Insurance contract or identification number | 10013748 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $18,944 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,265,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,309 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | PACIFIC BENEFIT CONSULTANTS, INC. |
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