KAIROS NORTHWEST has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: KAIROS NW GROUP HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 64 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 59 |
| Total of all active and inactive participants | 2022-07-01 | 59 |
| Total participants | 2022-07-01 | 59 |
| 2021: KAIROS NW GROUP HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 93 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 65 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 65 |
| Total participants | 2021-07-01 | 65 |
| 2020: KAIROS NW GROUP HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 93 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 93 |
| Total participants | 2020-07-01 | 93 |
| 2019: KAIROS NW GROUP HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 109 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 109 |
| Total participants | 2019-07-01 | 109 |
| 2018: KAIROS NW GROUP HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 130 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 118 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 118 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-07-01 | 0 |
| Total participants | 2018-07-01 | 118 |
| 2017: KAIROS NW GROUP HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 130 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 130 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2017-07-01 | 0 |
| Total participants | 2017-07-01 | 130 |
| 2016: KAIROS NW GROUP HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 123 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 123 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2016-07-01 | 0 |
| Total participants | 2016-07-01 | 123 |
| 2015: KAIROS NW GROUP HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 128 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 128 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-07-01 | 0 |
| Total participants | 2015-07-01 | 128 |
| Number of participants with account balances | 2015-07-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2015-07-01 | 0 |
| 2014: KAIROS NW GROUP HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 122 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 122 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-07-01 | 0 |
| Total participants | 2014-07-01 | 122 |
| 2013: KAIROS NW GROUP HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 114 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 0 |
| Total of all active and inactive participants | 2013-07-01 | 114 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-07-01 | 0 |
| Total participants | 2013-07-01 | 114 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2013-07-01 | 0 |
| 2022: KAIROS NW GROUP HEALTH PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: KAIROS NW GROUP HEALTH PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Submission has been amended | No |
| 2021-07-01 | This submission is the final filing | No |
| 2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-07-01 | Plan is a collectively bargained plan | No |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: KAIROS NW GROUP HEALTH PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: KAIROS NW GROUP HEALTH PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: KAIROS NW GROUP HEALTH PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: KAIROS NW GROUP HEALTH PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Submission has been amended | No |
| 2017-07-01 | This submission is the final filing | No |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-07-01 | Plan is a collectively bargained plan | No |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: KAIROS NW GROUP HEALTH PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: KAIROS NW GROUP HEALTH PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: KAIROS NW GROUP HEALTH PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: KAIROS NW GROUP HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | First time form 5500 has been submitted | Yes |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10046844 |
| Policy instance | 1 |
| Insurance contract or identification number | 10046844 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $14,900 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $668,105 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,900 | | Insurance broker organization code? | 3 |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10046844 |
| Policy instance | 1 |
| Insurance contract or identification number | 10046844 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $15,860 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $763,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,860 | | Insurance broker organization code? | 3 |
|
| REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
| Policy contract number | 10046844 |
| Policy instance | 1 |
| Insurance contract or identification number | 10046844 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $26,700 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $936,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,700 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $15,421 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,054,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,421 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $13,531 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $891,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,531 | | Insurance broker organization code? | 3 |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $13,219 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $891,645 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $1,260 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $749,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,260 | | Insurance broker organization code? | 3 | | Insurance broker name | HART INSURANCE |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $13,288 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $741,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,288 | | Insurance broker organization code? | 3 | | Insurance broker name | HART INSURANCE |
|
| PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
| Policy contract number | 110933 |
| Policy instance | 1 |
| Insurance contract or identification number | 110933 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $11,236 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $600,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,236 | | Insurance broker organization code? | 3 | | Insurance broker name | HART INSURANCE |
|
