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DUTCH BROS. HEALTH & WELFARE PLAN 401k Plan overview

Plan NameDUTCH BROS. HEALTH & WELFARE PLAN
Plan identification number 501

DUTCH BROS. HEALTH & WELFARE PLAN Benefits

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

401k Sponsoring company profile

DUTCH BROS. LLC has sponsored the creation of one or more 401k plans.

Company Name:DUTCH BROS. LLC
Employer identification number (EIN):931233485
NAIC Classification:445299
NAIC Description:All Other Specialty Food Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DUTCH BROS. HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01JENNIFER LEWIS2023-07-12
5012021-01-01CHRISTINE SCHMIDT2022-10-12
5012020-01-01SARAH HANSEN2021-07-07
5012019-05-01
5012018-05-01
5012017-05-01CHRISTINE SCHMIDT
5012016-05-01CHRISTINE SCHMIDT

Plan Statistics for DUTCH BROS. HEALTH & WELFARE PLAN

401k plan membership statisitcs for DUTCH BROS. HEALTH & WELFARE PLAN

Measure Date Value
2022: DUTCH BROS. HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-011,391
Total number of active participants reported on line 7a of the Form 55002022-01-012,044
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-012,044
Number of employers contributing to the scheme2022-01-010
2021: DUTCH BROS. HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01934
Total number of active participants reported on line 7a of the Form 55002021-01-011,391
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-011,391
Number of employers contributing to the scheme2021-01-010
2020: DUTCH BROS. HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01760
Total number of active participants reported on line 7a of the Form 55002020-01-01934
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01934
Number of employers contributing to the scheme2020-01-010
2019: DUTCH BROS. HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01438
Total number of active participants reported on line 7a of the Form 55002019-05-01515
Number of retired or separated participants receiving benefits2019-05-012
Total of all active and inactive participants2019-05-01517
2018: DUTCH BROS. HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-05-01268
Total number of active participants reported on line 7a of the Form 55002018-05-01411
Number of retired or separated participants receiving benefits2018-05-014
Total of all active and inactive participants2018-05-01415
2017: DUTCH BROS. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01174
Total number of active participants reported on line 7a of the Form 55002017-05-01224
Number of retired or separated participants receiving benefits2017-05-011
Total of all active and inactive participants2017-05-01225
2016: DUTCH BROS. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01124
Total number of active participants reported on line 7a of the Form 55002016-05-01170
Number of retired or separated participants receiving benefits2016-05-011
Total of all active and inactive participants2016-05-01171

Form 5500 Responses for DUTCH BROS. HEALTH & WELFARE PLAN

2022: DUTCH BROS. HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: DUTCH BROS. HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DUTCH BROS. HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: DUTCH BROS. HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-05-01Plan funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2018: DUTCH BROS. HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-05-01Type of plan entitySingle employer plan
2018-05-01Plan funding arrangement – InsuranceYes
2018-05-01Plan benefit arrangement – InsuranceYes
2017: DUTCH BROS. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – InsuranceYes
2016: DUTCH BROS. HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01First time form 5500 has been submittedYes
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number431662
Policy instance 5
Insurance contract or identification number431662
Number of Individuals Covered523
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $9,605
Total amount of fees paid to insurance companyUSD $2,601
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 providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $86,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,605
Amount paid for insurance broker fees2601
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 number431660
Policy instance 4
Insurance contract or identification number431660
Number of Individuals Covered2044
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $7,315
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $269,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees7315
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered12981
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 $127,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberGRP00005388
Policy instance 2
Insurance contract or identification numberGRP00005388
Number of Individuals Covered1026
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,758
Total amount of fees paid to insurance companyUSD $3,676
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,758
Amount paid for insurance broker fees3676
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 1
Insurance contract or identification number10010259
Number of Individuals Covered1622
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $15,678
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $652,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $15,678
Amount paid for insurance broker fees0
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 1
Insurance contract or identification number10010259
Number of Individuals Covered1226
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $11,819
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $473,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,819
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberGRP00005388
Policy instance 2
Insurance contract or identification numberGRP00005388
Number of Individuals Covered756
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,325
Total amount of fees paid to insurance companyUSD $3,676
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,325
Amount paid for insurance broker fees3676
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number00
Policy instance 3
Insurance contract or identification number00
Number of Individuals Covered12981
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 $127,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH8P42
Policy instance 4
Insurance contract or identification numberH8P42
Number of Individuals Covered4
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $32
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number431660
Policy instance 5
Insurance contract or identification number431660
Number of Individuals Covered1391
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,389
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $169,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3389
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 )
Policy contract number431662
Policy instance 6
Insurance contract or identification number431662
Number of Individuals Covered402
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $8,145
Total amount of fees paid to insurance companyUSD $3,413
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 providedACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $70,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,145
Amount paid for insurance broker fees3413
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCPK
Policy instance 6
Insurance contract or identification numberGLUG0BCPK
Number of Individuals Covered935
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $13,643
Total amount of fees paid to insurance companyUSD $5,295
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $259,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,912
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATION
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberH8P42
Policy instance 5
Insurance contract or identification numberH8P42
Number of Individuals Covered4
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $182
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $3,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73
Amount paid for insurance broker fees0
Insurance broker organization code?3
RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number15058764
Policy instance 4
Insurance contract or identification number15058764
Number of Individuals Covered8228
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
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 $92,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberGRP00005388
Policy instance 3
Insurance contract or identification numberGRP00005388
Number of Individuals Covered627
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,909
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $63,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,646
Amount paid for insurance broker fees0
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 2
Insurance contract or identification number10010259
Number of Individuals Covered984
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,725
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $418,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $5,372
Amount paid for insurance broker fees0
Insurance broker organization code?3
REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )
Policy contract number10044017
Policy instance 1
Insurance contract or identification number10044017
Number of Individuals Covered909
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $149,272
Total amount of fees paid to insurance companyUSD $32,760
Health Insurance Welfare BenefitYes
Other welfare benefits providedCHIROPRACTIC/ACUPUNCTURE
Welfare Benefit Premiums Paid to CarrierUSD $4,700,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,250
Amount paid for insurance broker fees32760
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0BCPK
Policy instance 6
Insurance contract or identification numberGUG 0BCPK
Number of Individuals Covered749
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,453
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $53,808
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1453
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BCPK
Policy instance 1
Insurance contract or identification numberGLTD0BCPK
Number of Individuals Covered29
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $217
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees217
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number110863
Policy instance 2
Insurance contract or identification number110863
Number of Individuals Covered748
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $74,390
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Other welfare benefits providedCHIROPRACTIC ACUPUNCTURE
Welfare Benefit Premiums Paid to CarrierUSD $2,470,667
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $74,390
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 3
Insurance contract or identification number10010259
Number of Individuals Covered764
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,577
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $221,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,577
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCPK
Policy instance 4
Insurance contract or identification numberGLUG0BCPK
Number of Individuals Covered749
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $325
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $12,031
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees325
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0BCPK
Policy instance 5
Insurance contract or identification numberGUDH0BCPK
Number of Individuals Covered302
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,970
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $29,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,970
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BCPK
Policy instance 7
Insurance contract or identification numberGVTL0BCPK
Number of Individuals Covered248
Insurance policy start date2019-05-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,039
Total amount of fees paid to insurance companyUSD $505
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,039
Insurance broker organization code?5
Amount paid for insurance broker fees505
Additional information about fees paid to insurance brokerADMINISTRATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BCPK
Policy instance 7
Insurance contract or identification numberGVTL0BCPK
Number of Individuals Covered195
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $723
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,226
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees519
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BCPK
Policy instance 1
Insurance contract or identification numberGLTD0BCPK
Number of Individuals Covered1
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $148
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees74
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number110863
Policy instance 2
Insurance contract or identification number110863
Number of Individuals Covered242
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $73,026
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedCHIROPRACTIC ACUPUNCTURE
Welfare Benefit Premiums Paid to CarrierUSD $2,473,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,026
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 3
Insurance contract or identification number10010259
Number of Individuals Covered569
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $6,638
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $221,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,638
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCPK
Policy instance 4
Insurance contract or identification numberGLUG0BCPK
Number of Individuals Covered549
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $466
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees322
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0BCPK
Policy instance 5
Insurance contract or identification numberGUDH0BCPK
Number of Individuals Covered210
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $2,931
Total amount of fees paid to insurance companyUSD $309
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,931
Amount paid for insurance broker fees309
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0BCPK
Policy instance 6
Insurance contract or identification numberGUG 0BCPK
Number of Individuals Covered550
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $2,128
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1468
Additional information about fees paid to insurance brokerADMINISTRATION
Insurance broker organization code?5
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10010259
Policy instance 3
Insurance contract or identification number10010259
Number of Individuals Covered368
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $4,778
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $146,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 )
Policy contract number110863
Policy instance 2
Insurance contract or identification number110863
Number of Individuals Covered241
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $43,077
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Other welfare benefits providedCHIROPRACTIC
Welfare Benefit Premiums Paid to CarrierUSD $1,371,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT001038
Policy instance 1
Insurance contract or identification numberWBT001038
Number of Individuals Covered308
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $5,764
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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