TILLAMOOK COUNTRY SMOKER, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN
401k plan membership statisitcs for TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2016: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-04-01 | 141 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 136 |
| Number of retired or separated participants receiving benefits | 2016-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-04-01 | 0 |
| Total of all active and inactive participants | 2016-04-01 | 136 |
| 2015: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 141 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-04-01 | 0 |
| Total of all active and inactive participants | 2015-04-01 | 141 |
| 2014: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 141 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 150 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-04-01 | 0 |
| Total of all active and inactive participants | 2014-04-01 | 150 |
| 2013: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 141 |
| Total of all active and inactive participants | 2013-04-01 | 141 |
| 2012: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 137 |
| Total of all active and inactive participants | 2012-04-01 | 137 |
| 2011: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-04-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-04-01 | 150 |
| Total of all active and inactive participants | 2011-04-01 | 150 |
| 2010: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-04-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-04-01 | 144 |
| Total of all active and inactive participants | 2010-04-01 | 144 |
| 2016: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: TILLAMOOK COUNTRY SMOKER, INC WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD606544 |
| Policy instance | 2 |
| Insurance contract or identification number | SGD606544 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $550 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $550 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM606346 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM606346 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,281 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,281 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0030398 |
| Policy instance | 1 |
| Insurance contract or identification number | G0030398 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $22,211 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $735,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,211 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK604478 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK604478 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $107 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,066 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $107 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVDISON BENEFITS PLANNING LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT601491 |
| Policy instance | 5 |
| Insurance contract or identification number | VDT601491 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,995 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,995 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | CI960086 |
| Policy instance | 6 |
| Insurance contract or identification number | CI960086 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $441 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $2,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $441 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI960080 |
| Policy instance | 7 |
| Insurance contract or identification number | AI960080 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,066 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,066 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 6 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $2,214 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,840 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $738 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 4 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $2,230 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,270 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 3 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $2,564 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,056 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 2 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $871 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $7,121 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $502 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0030398 |
| Policy instance | 1 |
| Insurance contract or identification number | G0030398 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $29,028 | | Health 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 $29,028 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 5 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $21 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $90 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 6 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,636 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $545 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 4 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,994 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,137 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 3 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $2,550 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,050 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 2 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $892 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $7,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $507 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0030398 |
| Policy instance | 1 |
| Insurance contract or identification number | G0030398 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $27,386 | | Health Insurance Welfare Benefit | Yes | | Were dividends or retroactive rate refunds paid in cash? | 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 $27,386 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 5 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $12 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $54 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0030398 |
| Policy instance | 1 |
| Insurance contract or identification number | G0030398 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $25,061 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $834,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,061 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 5 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,071 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $172 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 4 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $2,528 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $424 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 3 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,979 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $374 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIDSON BENEFITS PLANNING |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50014444 |
| Policy instance | 2 |
| Insurance contract or identification number | 50014444 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $735 | | Total amount of fees paid to insurance company | USD $301 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $186 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 301 | | Additional information about fees paid to insurance broker | ADDT'L COMPENSATION | | Insurance broker name | DAVIDSON BENEFITS PLANNING LLC |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR530556 0000 |
| Policy instance | 2 |
| Insurance contract or identification number | OR530556 0000 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $2,555 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATHDISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
| Policy contract number | G0030398 |
| Policy instance | 1 |
| Insurance contract or identification number | G0030398 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $24,379 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $813,659 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR530556-5000 |
| Policy instance | 3 |
| Insurance contract or identification number | OR530556-5000 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $3,803 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR530556 0000 |
| Policy instance | 3 |
| Insurance contract or identification number | OR530556 0000 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $2,102 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATHDISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 94188 ) |
| Policy contract number | OR530556-5000 |
| Policy instance | 4 |
| Insurance contract or identification number | OR530556-5000 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $3,884 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE HEALTH PLAN OF OREGON, INC. (National Association of Insurance Commissioners NAIC id number: 84930 ) |
| Policy contract number | 1030556-0001 |
| Policy instance | 1 |
| Insurance contract or identification number | 1030556-0001 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $24,353 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $811,750 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFEWISE HEALTH PLAN OF OREGON, INC. (National Association of Insurance Commissioners NAIC id number: 84930 ) |
| Policy contract number | 1030556-0002 |
| Policy instance | 2 |
| Insurance contract or identification number | 1030556-0002 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $181 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,024 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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