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NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 401k Plan overview

Plan NameNEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN
Plan identification number 501

NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

NEIGHBORIMPACT has sponsored the creation of one or more 401k plans.

Company Name:NEIGHBORIMPACT
Employer identification number (EIN):930884929
NAIC Classification:624100
NAIC Description: Individual and Family Services

Additional information about NEIGHBORIMPACT

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division
Incorporation Date: 1984-12-05
Company Identification Number: 20638615
Legal Registered Office Address: 2303 SW FIRST ST

REDMOND
United States of America (USA)
97756

More information about NEIGHBORIMPACT

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-07-01SCOTT COOPER2024-01-10
5012021-07-01SCOTT COOPER2023-01-27
5012020-07-01SCOTT COOPER2022-01-27
5012019-07-01SCOTT COOPER2021-01-29
5012018-07-01ELAINE SALMONSON2019-12-12
5012017-07-01
5012016-07-01
5012015-07-01KIM LONIEN
5012014-12-01ELAINE SALMONSON
5012013-12-01ELAINE SALMONSON
5012012-12-01SCOTT COOPER
5012011-12-01CHERYL OPPERMAN
5012009-12-01SHARON MILLER

Plan Statistics for NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN

401k plan membership statisitcs for NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN

Measure Date Value
2022: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-07-01234
Total number of active participants reported on line 7a of the Form 55002022-07-01240
Number of retired or separated participants receiving benefits2022-07-010
Number of other retired or separated participants entitled to future benefits2022-07-010
Total of all active and inactive participants2022-07-01240
Number of employers contributing to the scheme2022-07-010
2021: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01204
Total number of active participants reported on line 7a of the Form 55002021-07-01234
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01234
Number of employers contributing to the scheme2021-07-010
2020: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01163
Total number of active participants reported on line 7a of the Form 55002020-07-01204
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01204
Number of employers contributing to the scheme2020-07-010
2019: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01159
Total number of active participants reported on line 7a of the Form 55002019-07-01163
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01163
Number of employers contributing to the scheme2019-07-010
2018: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-01139
Total number of active participants reported on line 7a of the Form 55002018-07-01182
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01182
Number of employers contributing to the scheme2018-07-010
2017: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01175
Total number of active participants reported on line 7a of the Form 55002017-07-01139
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01139
2016: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01162
Total number of active participants reported on line 7a of the Form 55002016-07-01175
Number of retired or separated participants receiving benefits2016-07-010
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01175
2015: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01132
Total number of active participants reported on line 7a of the Form 55002015-07-01162
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01162
2014: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-12-01157
Total number of active participants reported on line 7a of the Form 55002014-12-01132
Number of retired or separated participants receiving benefits2014-12-010
Number of other retired or separated participants entitled to future benefits2014-12-010
Total of all active and inactive participants2014-12-01132
2013: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-12-01136
Total number of active participants reported on line 7a of the Form 55002013-12-01157
Number of retired or separated participants receiving benefits2013-12-010
Number of other retired or separated participants entitled to future benefits2013-12-010
Total of all active and inactive participants2013-12-01157
2012: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-12-01132
Total number of active participants reported on line 7a of the Form 55002012-12-01136
Number of retired or separated participants receiving benefits2012-12-010
Number of other retired or separated participants entitled to future benefits2012-12-010
Total of all active and inactive participants2012-12-01136
2011: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-12-01130
Total number of active participants reported on line 7a of the Form 55002011-12-01132
Total of all active and inactive participants2011-12-01132
2009: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-12-01115
Total number of active participants reported on line 7a of the Form 55002009-12-01128
Number of retired or separated participants receiving benefits2009-12-010
Number of other retired or separated participants entitled to future benefits2009-12-010
Total of all active and inactive participants2009-12-01128
Total participants2009-12-01128

Form 5500 Responses for NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN

2022: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan funding arrangement – General assets of the sponsorYes
2022-07-01Plan benefit arrangement – InsuranceYes
2022-07-01Plan benefit arrangement – General assets of the sponsorYes
2021: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – General assets of the sponsorYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – General assets of the sponsorYes
2017: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan funding arrangement – General assets of the sponsorYes
2017-07-01Plan benefit arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – General assets of the sponsorYes
2016: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan funding arrangement – General assets of the sponsorYes
2016-07-01Plan benefit arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – General assets of the sponsorYes
2015: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-12-01Type of plan entitySingle employer plan
2014-12-01Submission has been amendedNo
2014-12-01This submission is the final filingNo
2014-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2014-12-01Plan is a collectively bargained planNo
2014-12-01Plan funding arrangement – InsuranceYes
2014-12-01Plan funding arrangement – General assets of the sponsorYes
2014-12-01Plan benefit arrangement – InsuranceYes
2014-12-01Plan benefit arrangement – General assets of the sponsorYes
2013: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-12-01Type of plan entitySingle employer plan
2013-12-01Submission has been amendedNo
2013-12-01This submission is the final filingNo
2013-12-01This return/report is a short plan year return/report (less than 12 months)No
2013-12-01Plan is a collectively bargained planNo
2013-12-01Plan funding arrangement – InsuranceYes
2013-12-01Plan funding arrangement – General assets of the sponsorYes
2013-12-01Plan benefit arrangement – InsuranceYes
2013-12-01Plan benefit arrangement – General assets of the sponsorYes
2012: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-12-01Type of plan entitySingle employer plan
2012-12-01Submission has been amendedNo
2012-12-01This submission is the final filingNo
2012-12-01This return/report is a short plan year return/report (less than 12 months)No
2012-12-01Plan is a collectively bargained planNo
2012-12-01Plan funding arrangement – InsuranceYes
2012-12-01Plan benefit arrangement – InsuranceYes
2011: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-12-01Type of plan entitySingle employer plan
2011-12-01Submission has been amendedNo
2011-12-01This submission is the final filingNo
2011-12-01This return/report is a short plan year return/report (less than 12 months)No
2011-12-01Plan is a collectively bargained planNo
2011-12-01Plan funding arrangement – InsuranceYes
2011-12-01Plan benefit arrangement – InsuranceYes
2009: NEIGHBORIMPACT EMPLOYEE WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-12-01Type of plan entitySingle employer plan
2009-12-01Submission has been amendedNo
2009-12-01This submission is the final filingNo
2009-12-01This return/report is a short plan year return/report (less than 12 months)No
2009-12-01Plan is a collectively bargained planNo
2009-12-01Plan funding arrangement – InsuranceYes
2009-12-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number851475
Policy instance 4
Insurance contract or identification number851475
Number of Individuals Covered211
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $5,695
Total amount of fees paid to insurance companyUSD $2,010
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $36,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,695
Amount paid for insurance broker fees2010
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered240
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $8,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered266
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $39,867
Total amount of fees paid to insurance companyUSD $1,920
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,946,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,867
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerNEW GROUP/RETENTION BONUS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered206
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $1,417
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $30,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,417
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered207
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $1,508
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,508
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered259
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $36,763
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,770,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,763
Amount paid for insurance broker fees0
Insurance broker organization code?3
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered234
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $7,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number851475
Policy instance 4
Insurance contract or identification number851475
Number of Individuals Covered199
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $6,071
Total amount of fees paid to insurance companyUSD $1,384
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $42,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,071
Amount paid for insurance broker fees1384
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered203
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $1,327
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,327
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered258
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $31,403
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,521,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,403
Amount paid for insurance broker fees0
Insurance broker organization code?3
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered240
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $6,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number851475
Policy instance 4
Insurance contract or identification number851475
Number of Individuals Covered203
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $3,841
Total amount of fees paid to insurance companyUSD $436
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $27,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,841
Amount paid for insurance broker fees436
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered160
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $357
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $357
Amount paid for insurance broker fees0
Insurance broker organization code?3
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered214
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $26,413
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,256,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,413
Amount paid for insurance broker fees0
Insurance broker organization code?3
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered190
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $5,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WELLWORKS FOR YOU (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12198
Policy instance 4
Insurance contract or identification number12198
Number of Individuals Covered163
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number851475
Policy instance 5
Insurance contract or identification number851475
Number of Individuals Covered157
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $4,092
Total amount of fees paid to insurance companyUSD $241
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $28,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,092
Amount paid for insurance broker fees241
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number851475
Policy instance 4
Insurance contract or identification number851475
Number of Individuals Covered143
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $3,374
Total amount of fees paid to insurance companyUSD $423
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $21,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,374
Amount paid for insurance broker fees423
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered182
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $5,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered210
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $23,775
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,115,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,775
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered141
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $1,149
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,149
Amount paid for insurance broker fees0
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50016513
Policy instance 4
Insurance contract or identification number50016513
Number of Individuals Covered139
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $3,743
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $16,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,506
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCONNEXION INSURANCE SOLUTIONS, INC.
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered182
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $5,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered214
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $19,297
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $953,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,297
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NORTHWEST
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 1
Insurance contract or identification number30058762
Number of Individuals Covered138
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $1,076
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,076
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NORTHWEST
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 0 )
Policy contract numberVC688 ET AL
Policy instance 1
Insurance contract or identification numberVC688 ET AL
Number of Individuals Covered131
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $15,195
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $868,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,195
Insurance broker organization code?3
Insurance broker nameUSI NORTHWEST
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 2
Insurance contract or identification numberG0033464
Number of Individuals Covered214
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $3,372
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $91,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,372
Insurance broker organization code?3
Insurance broker nameUSI NORTHWEST
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50016513
Policy instance 3
Insurance contract or identification number50016513
Number of Individuals Covered134
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $3,497
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $17,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,016
Insurance broker organization code?3
Insurance broker nameKIBBLE AND PRENTICE HOLDING COMPANY
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered162
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $4,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30058762
Policy instance 5
Insurance contract or identification number30058762
Number of Individuals Covered133
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $870
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $13,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $868
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0033464
Policy instance 4
Insurance contract or identification numberG0033464
Number of Individuals Covered196
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $3,086
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $79,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,086
Insurance broker organization code?3
Insurance broker nameUSI NORTHWEST
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 0 )
Policy contract numberVC688 ET AL
Policy instance 1
Insurance contract or identification numberVC688 ET AL
Number of Individuals Covered137
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $16,180
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $924,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,980
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50016513
Policy instance 2
Insurance contract or identification number50016513
Number of Individuals Covered132
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $3,437
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $15,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,517
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
CASCADE CENTERS INC. (National Association of Insurance Commissioners NAIC id number: 62133 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered182
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $4,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MHN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 4
Insurance contract or identification number00
Number of Individuals Covered157
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE 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 CarrierUSD $4,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker name
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 0 )
Policy contract numberVC688 ET AL
Policy instance 1
Insurance contract or identification numberVC688 ET AL
Number of Individuals Covered134
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $15,952
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $834,165
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,952
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number649841
Policy instance 2
Insurance contract or identification number649841
Number of Individuals Covered136
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $2,207
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $2,207
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50016513
Policy instance 3
Insurance contract or identification number50016513
Number of Individuals Covered149
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $1,234
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $16,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $1,234
Insurance broker namePREMERA BLUE CROSS
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0020362
Policy instance 1
Insurance contract or identification numberG0020362
Number of Individuals Covered141
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $15,337
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $870,612
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,337
Insurance broker organization code?3
Insurance broker nameAPEX INSURANCE BENEFITS LLC
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number649841
Policy instance 2
Insurance contract or identification number649841
Number of Individuals Covered140
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $2,117
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 BrokerUSD $2,117
Insurance broker organization code?3
Insurance broker nameAPEX INSURANCE BENEFITS LLC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50016513
Policy instance 3
Insurance contract or identification number50016513
Number of Individuals Covered125
Insurance policy start date2012-12-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $2,322
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $10,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,551
Insurance broker organization code?3
Insurance broker namePREMERA BLUE CROSS
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0020362
Policy instance 3
Insurance contract or identification numberG0020362
Number of Individuals Covered132
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $16,188
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $875,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number293782
Policy instance 1
Insurance contract or identification number293782
Number of Individuals Covered30
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $1,633
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number649841
Policy instance 2
Insurance contract or identification number649841
Number of Individuals Covered124
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $1,477
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number293778
Policy instance 4
Insurance contract or identification number293778
Number of Individuals Covered124
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $476
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract numberG0020362
Policy instance 2
Insurance contract or identification numberG0020362
Number of Individuals Covered125
Insurance policy start date2010-12-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $10,802
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $674,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number293778
Policy instance 1
Insurance contract or identification number293778
Number of Individuals Covered130
Insurance policy start date2010-12-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $884
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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