HEAD START OF LANE COUNTY has sponsored the creation of one or more 401k plans.
Measure | Date | Value |
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2021: HEAD START OF LANE COUNTY 2021 401k membership |
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Total participants, beginning-of-year | 2021-10-01 | 200 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 277 |
Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
Total of all active and inactive participants | 2021-10-01 | 277 |
Number of employers contributing to the scheme | 2021-10-01 | 0 |
2020: HEAD START OF LANE COUNTY 2020 401k membership |
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Total participants, beginning-of-year | 2020-10-01 | 217 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 200 |
Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
Total of all active and inactive participants | 2020-10-01 | 200 |
Number of employers contributing to the scheme | 2020-10-01 | 0 |
2019: HEAD START OF LANE COUNTY 2019 401k membership |
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Total participants, beginning-of-year | 2019-10-01 | 237 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 241 |
Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
Total of all active and inactive participants | 2019-10-01 | 241 |
Number of employers contributing to the scheme | 2019-10-01 | 0 |
2018: HEAD START OF LANE COUNTY 2018 401k membership |
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Total participants, beginning-of-year | 2018-10-01 | 238 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 246 |
Number of retired or separated participants receiving benefits | 2018-10-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
Total of all active and inactive participants | 2018-10-01 | 247 |
Number of employers contributing to the scheme | 2018-10-01 | 0 |
2017: HEAD START OF LANE COUNTY 2017 401k membership |
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Total participants, beginning-of-year | 2017-10-01 | 226 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 238 |
Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
Total of all active and inactive participants | 2017-10-01 | 238 |
Number of employers contributing to the scheme | 2017-10-01 | 0 |
2016: HEAD START OF LANE COUNTY 2016 401k membership |
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Total participants, beginning-of-year | 2016-10-01 | 234 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 226 |
Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
Total of all active and inactive participants | 2016-10-01 | 226 |
2015: HEAD START OF LANE COUNTY 2015 401k membership |
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Total participants, beginning-of-year | 2015-10-01 | 229 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 234 |
Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
Total of all active and inactive participants | 2015-10-01 | 234 |
2014: HEAD START OF LANE COUNTY 2014 401k membership |
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Total participants, beginning-of-year | 2014-10-01 | 226 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 229 |
Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
Total of all active and inactive participants | 2014-10-01 | 229 |
2013: HEAD START OF LANE COUNTY 2013 401k membership |
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Total participants, beginning-of-year | 2013-10-01 | 227 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 226 |
Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
Total of all active and inactive participants | 2013-10-01 | 226 |
2012: HEAD START OF LANE COUNTY 2012 401k membership |
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Total participants, beginning-of-year | 2012-10-01 | 239 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 227 |
Number of retired or separated participants receiving benefits | 2012-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
Total of all active and inactive participants | 2012-10-01 | 227 |
2011: HEAD START OF LANE COUNTY 2011 401k membership |
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Total participants, beginning-of-year | 2011-10-01 | 223 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 239 |
Number of retired or separated participants receiving benefits | 2011-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
Total of all active and inactive participants | 2011-10-01 | 239 |
2010: HEAD START OF LANE COUNTY 2010 401k membership |
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Total participants, beginning-of-year | 2010-10-01 | 246 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 223 |
Number of retired or separated participants receiving benefits | 2010-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2010-10-01 | 0 |
Total of all active and inactive participants | 2010-10-01 | 223 |
2009: HEAD START OF LANE COUNTY 2009 401k membership |
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Total participants, beginning-of-year | 2009-10-01 | 229 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 246 |
Total of all active and inactive participants | 2009-10-01 | 246 |
Total participants | 2009-10-01 | 246 |
2021: HEAD START OF LANE COUNTY 2021 form 5500 responses |
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2021-10-01 | Type of plan entity | Single employer plan |
2021-10-01 | Plan funding arrangement – Insurance | Yes |
2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-10-01 | Plan benefit arrangement – Insurance | Yes |
2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: HEAD START OF LANE COUNTY 2020 form 5500 responses |
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2020-10-01 | Type of plan entity | Single employer plan |
2020-10-01 | Plan funding arrangement – Insurance | Yes |
2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-10-01 | Plan benefit arrangement – Insurance | Yes |
2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: HEAD START OF LANE COUNTY 2019 form 5500 responses |
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2019-10-01 | Type of plan entity | Single employer plan |
2019-10-01 | Plan funding arrangement – Insurance | Yes |
2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-10-01 | Plan benefit arrangement – Insurance | Yes |
2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: HEAD START OF LANE COUNTY 2018 form 5500 responses |
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2018-10-01 | Type of plan entity | Single employer plan |
2018-10-01 | Plan funding arrangement – Insurance | Yes |
2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-10-01 | Plan benefit arrangement – Insurance | Yes |
2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: HEAD START OF LANE COUNTY 2017 form 5500 responses |
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2017-10-01 | Type of plan entity | Single employer plan |
2017-10-01 | Plan funding arrangement – Insurance | Yes |
2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-10-01 | Plan benefit arrangement – Insurance | Yes |
2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: HEAD START OF LANE COUNTY 2016 form 5500 responses |
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2016-10-01 | Type of plan entity | Single employer plan |
2016-10-01 | Submission has been amended | No |
2016-10-01 | This submission is the final filing | No |
2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-10-01 | Plan is a collectively bargained plan | No |
2016-10-01 | Plan funding arrangement – Insurance | Yes |
2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-10-01 | Plan benefit arrangement – Insurance | Yes |
2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: HEAD START OF LANE COUNTY 2015 form 5500 responses |
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2015-10-01 | Type of plan entity | Single employer plan |
2015-10-01 | Submission has been amended | No |
2015-10-01 | This submission is the final filing | No |
2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-10-01 | Plan is a collectively bargained plan | No |
2015-10-01 | Plan funding arrangement – Insurance | Yes |
2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-10-01 | Plan benefit arrangement – Insurance | Yes |
2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: HEAD START OF LANE COUNTY 2014 form 5500 responses |
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2014-10-01 | Type of plan entity | Single employer plan |
2014-10-01 | Submission has been amended | No |
2014-10-01 | This submission is the final filing | No |
2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-10-01 | Plan is a collectively bargained plan | No |
2014-10-01 | Plan funding arrangement – Insurance | Yes |
2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-10-01 | Plan benefit arrangement – Insurance | Yes |
2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: HEAD START OF LANE COUNTY 2013 form 5500 responses |
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2013-10-01 | Type of plan entity | Single employer plan |
2013-10-01 | Submission has been amended | No |
2013-10-01 | This submission is the final filing | No |
2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-10-01 | Plan is a collectively bargained plan | No |
2013-10-01 | Plan funding arrangement – Insurance | Yes |
2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-10-01 | Plan benefit arrangement – Insurance | Yes |
2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: HEAD START OF LANE COUNTY 2012 form 5500 responses |
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2012-10-01 | Type of plan entity | Single employer plan |
2012-10-01 | Submission has been amended | No |
2012-10-01 | This submission is the final filing | No |
2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-10-01 | Plan is a collectively bargained plan | No |
2012-10-01 | Plan funding arrangement – Insurance | Yes |
2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-10-01 | Plan benefit arrangement – Insurance | Yes |
2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: HEAD START OF LANE COUNTY 2011 form 5500 responses |
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2011-10-01 | Type of plan entity | Single employer plan |
2011-10-01 | Submission has been amended | No |
2011-10-01 | This submission is the final filing | No |
2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-10-01 | Plan is a collectively bargained plan | No |
2011-10-01 | Plan funding arrangement – Insurance | Yes |
2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-10-01 | Plan benefit arrangement – Insurance | Yes |
2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2010: HEAD START OF LANE COUNTY 2010 form 5500 responses |
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2010-10-01 | Type of plan entity | Single employer plan |
2010-10-01 | Submission has been amended | No |
2010-10-01 | This submission is the final filing | No |
2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-10-01 | Plan is a collectively bargained plan | No |
2010-10-01 | Plan funding arrangement – Insurance | Yes |
2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2010-10-01 | Plan benefit arrangement – Insurance | Yes |
2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: HEAD START OF LANE COUNTY 2009 form 5500 responses |
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2009-10-01 | Type of plan entity | Single employer plan |
2009-10-01 | Submission has been amended | Yes |
2009-10-01 | This submission is the final filing | No |
2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-10-01 | Plan is a collectively bargained plan | No |
2009-10-01 | Plan funding arrangement – Insurance | Yes |
2009-10-01 | Plan benefit arrangement – Insurance | Yes |
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BYGS |
Policy instance | 4 |
Insurance contract or identification number | GLUG0BYGS | Number of Individuals Covered | 254 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $12,355 | Total amount of fees paid to insurance company | USD $852 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $85,207 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,355 | Amount paid for insurance broker fees | 852 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (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 | 277 | 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 | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $12,282 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56 |
Policy instance | 2 |
Insurance contract or identification number | OR56 | Number of Individuals Covered | 223 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $5,719 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | 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 | Commission paid to Insurance Broker | USD $5,719 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
Policy contract number | 22042 |
Policy instance | 1 |
Insurance contract or identification number | 22042 | Number of Individuals Covered | 205 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $42,840 | Total amount of fees paid to insurance company | USD $785 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,919,593 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $42,840 | Amount paid for insurance broker fees | 785 | Additional information about fees paid to insurance broker | DENTAL NEW MEMBERS BONUS, NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 1 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 52 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,974 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $44,337 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,974 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (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 | 200 | 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 | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $10,821 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56 |
Policy instance | 2 |
Insurance contract or identification number | OR56 | Number of Individuals Covered | 238 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $6,139 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | 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 | Commission paid to Insurance Broker | USD $6,139 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
Policy contract number | 22042 |
Policy instance | 4 |
Insurance contract or identification number | 22042 | Number of Individuals Covered | 195 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $40,247 | Total amount of fees paid to insurance company | USD $1,193 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,777,545 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $40,247 | Amount paid for insurance broker fees | 1193 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION BONUS | Insurance broker organization code? | 3 |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 5 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 252 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $8,398 | Total amount of fees paid to insurance company | USD $1,544 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $89,570 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,398 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BROKER BONUS |
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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
Policy contract number | 22042 |
Policy instance | 5 |
Insurance contract or identification number | 22042 | Number of Individuals Covered | 212 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $37,276 | Total amount of fees paid to insurance company | USD $5,000 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,822,984 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,276 | Amount paid for insurance broker fees | 5000 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56 |
Policy instance | 2 |
Insurance contract or identification number | OR56 | Number of Individuals Covered | 242 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $6,416 | 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? | Yes | Commission paid to Insurance Broker | USD $6,416 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 1 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 53 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $2,028 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $45,289 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,028 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (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 | 241 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $7,958 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 10188791001 |
Policy instance | 4 |
Insurance contract or identification number | 10188791001 | Number of Individuals Covered | 153 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $907 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $9,522 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $907 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 6 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 278 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $6,714 | Total amount of fees paid to insurance company | USD $2,307 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $75,851 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,714 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BROKER BONUS |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 6 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 246 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $6,128 | Total amount of fees paid to insurance company | USD $1,390 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $60,012 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,128 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BROKER BONUS |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56 |
Policy instance | 2 |
Insurance contract or identification number | OR56 | Number of Individuals Covered | 231 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $6,014 | 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 $6,014 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (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 | 246 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $7,905 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
Policy contract number | 1018879 |
Policy instance | 4 |
Insurance contract or identification number | 1018879 | Number of Individuals Covered | 104 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $300 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $7,262 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $300 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 ) |
Policy contract number | 22042 |
Policy instance | 5 |
Insurance contract or identification number | 22042 | Number of Individuals Covered | 193 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $37,090 | Total amount of fees paid to insurance company | USD $3,250 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,785,840 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,090 | Amount paid for insurance broker fees | 3250 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 1 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 65 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $2,676 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $54,109 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,676 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 5 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 238 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $5,404 | Total amount of fees paid to insurance company | USD $1,285 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $54,327 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56 |
Policy instance | 3 |
Insurance contract or identification number | OR56 | Number of Individuals Covered | 224 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $5,320 | 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? | Yes |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 2 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 86 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $3,312 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $60,910 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 230 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $50,168 | 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 $1,821,590 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 4 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 238 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $8,183 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 260 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $7,620 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 4 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 234 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $5,201 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $48,560 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,818 | Insurance broker organization code? | 3 | Insurance broker name | USI NORTHWEST |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR56/Z626 |
Policy instance | 3 |
Insurance contract or identification number | OR56/Z626 | Number of Individuals Covered | 179 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $4,246 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,246 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 2 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 124 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $2,443 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 $74,723 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,443 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 243 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $20,169 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,508,014 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,169 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 234 | Insurance policy start date | 2014-10-01 | Insurance policy end date | 2015-09-30 | Total amount of commissions paid to insurance broker | USD $20,518 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,482,093 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,518 | Insurance broker organization code? | 3 | Insurance broker name | USI NORTHWEST |
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PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 ) |
Policy contract number | G0033523 |
Policy instance | 2 |
Insurance contract or identification number | G0033523 | Number of Individuals Covered | 128 | Insurance policy start date | 2014-10-01 | Insurance policy end date | 2015-09-30 | Total amount of commissions paid to insurance broker | USD $2,233 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $73,856 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,233 | Insurance broker organization code? | 3 | Insurance broker name | USI NORTHWEST |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | Z626/OR56 |
Policy instance | 3 |
Insurance contract or identification number | Z626/OR56 | Number of Individuals Covered | 183 | Insurance policy start date | 2014-10-01 | Insurance policy end date | 2015-09-30 | Total amount of commissions paid to insurance broker | USD $4,324 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,324 | Insurance broker organization code? | 3 | Insurance broker name | USI NORTHWEST |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 263 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $7,905 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 4 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 229 | Insurance policy start date | 2014-10-01 | Insurance policy end date | 2015-09-30 | Total amount of commissions paid to insurance broker | USD $5,431 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $50,981 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,431 | Insurance broker organization code? | 3 | Insurance broker name | USI NORTHWEST |
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STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 649934 |
Policy instance | 5 |
Insurance contract or identification number | 649934 | Number of Individuals Covered | 93 | Insurance policy start date | 2013-10-01 | Insurance policy end date | 2014-09-30 | Total amount of commissions paid to insurance broker | USD $2,014 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 $65,941 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,924 | Insurance broker organization code? | 3 | Insurance broker name | CAMPBELL GALT AND NEWLANDS, INC. |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 4 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 210 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $7,275 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10181096 |
Policy instance | 3 |
Insurance contract or identification number | 10181096 | Number of Individuals Covered | 219 | Insurance policy start date | 2013-10-01 | Insurance policy end date | 2014-09-30 | Total amount of commissions paid to insurance broker | USD $4,401 | Total amount of fees paid to insurance company | USD $1,374 | 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 | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $39,852 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,216 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 1374 | Additional information about fees paid to insurance broker | BROKER BONUS | Insurance broker name | CAMPBELL GALT AND NEWLANDS, INC. |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | Z626/OR56 |
Policy instance | 2 |
Insurance contract or identification number | Z626/OR56 | Number of Individuals Covered | 304 | Insurance policy start date | 2013-10-01 | Insurance policy end date | 2014-09-30 | Total amount of commissions paid to insurance broker | USD $4,140 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,140 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, INC. |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 226 | Insurance policy start date | 2013-10-01 | Insurance policy end date | 2014-09-30 | Total amount of commissions paid to insurance broker | USD $18,703 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,345,638 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,313 | Insurance broker organization code? | 3 | Insurance broker name | USI INSURANCE SERVICES, LLC |
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STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
Policy contract number | 649934 |
Policy instance | 6 |
Insurance contract or identification number | 649934 | Number of Individuals Covered | 113 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $2,259 | Total amount of fees paid to insurance company | USD $2,632 | 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,325 | Amount paid for insurance broker fees | 1316 | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 240 | Insurance policy start date | 2012-01-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $7,223 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | LTD116854 |
Policy instance | 4 |
Insurance contract or identification number | LTD116854 | Number of Individuals Covered | 24 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $1,236 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Yes | 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 $8,242 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,236 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 12333 |
Policy instance | 3 |
Insurance contract or identification number | 12333 | Number of Individuals Covered | 227 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $3,613 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $37,505 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,613 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | Z626/OR56 |
Policy instance | 2 |
Insurance contract or identification number | Z626/OR56 | Number of Individuals Covered | 171 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $3,652 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $3,652 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 438 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $22,251 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,598,060 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,251 | Insurance broker organization code? | 3 | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 500 | Insurance policy start date | 2011-10-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $21,509 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,338,228 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 240 | Insurance policy start date | 2011-01-01 | Insurance policy end date | 2011-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $7,178 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 12333 |
Policy instance | 3 |
Insurance contract or identification number | 12333 | Number of Individuals Covered | 239 | Insurance policy start date | 2011-10-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $6,463 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $123,852 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | LTD116854 |
Policy instance | 4 |
Insurance contract or identification number | LTD116854 | Number of Individuals Covered | 25 | Insurance policy start date | 2011-10-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $944 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Yes | 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 $6,296 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | Z626 |
Policy instance | 2 |
Insurance contract or identification number | Z626 | Number of Individuals Covered | 101 | Insurance policy start date | 2011-10-01 | Insurance policy end date | 2012-09-30 | Total amount of commissions paid to insurance broker | USD $3,348 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | Z626 |
Policy instance | 2 |
Insurance contract or identification number | Z626 | Number of Individuals Covered | 153 | Insurance policy start date | 2010-10-01 | Insurance policy end date | 2011-09-30 | Total amount of commissions paid to insurance broker | USD $3,296 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | 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 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 250 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $2,040 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
Policy contract number | LTD116854 |
Policy instance | 4 |
Insurance contract or identification number | LTD116854 | Number of Individuals Covered | 22 | Insurance policy start date | 2010-10-01 | Insurance policy end date | 2011-09-30 | Total amount of commissions paid to insurance broker | USD $1,061 | Total amount of fees paid to insurance company | USD $115 | 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 | No | 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 | Yes | 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 $7,073 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 12333 |
Policy instance | 3 |
Insurance contract or identification number | 12333 | Number of Individuals Covered | 223 | Insurance policy start date | 2010-10-01 | Insurance policy end date | 2011-09-30 | Total amount of commissions paid to insurance broker | USD $3,234 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | 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 $36,702 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 100377 |
Policy instance | 1 |
Insurance contract or identification number | 100377 | Number of Individuals Covered | 472 | Insurance policy start date | 2010-10-01 | Insurance policy end date | 2011-09-30 | Total amount of commissions paid to insurance broker | USD $27,635 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | 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 $1,641,675 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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