DUTCH BROS. LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DUTCH BROS. HEALTH & WELFARE PLAN
401k plan membership statisitcs for DUTCH BROS. HEALTH & WELFARE PLAN
Measure | Date | Value |
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2022: DUTCH BROS. HEALTH & WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 1,391 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 2,044 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 2,044 |
Number of employers contributing to the scheme | 2022-01-01 | 0 |
2021: DUTCH BROS. HEALTH & WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 934 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 1,391 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 1,391 |
Number of employers contributing to the scheme | 2021-01-01 | 0 |
2020: DUTCH BROS. HEALTH & WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 760 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 934 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
Total of all active and inactive participants | 2020-01-01 | 934 |
Number of employers contributing to the scheme | 2020-01-01 | 0 |
2019: DUTCH BROS. HEALTH & WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-05-01 | 438 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 515 |
Number of retired or separated participants receiving benefits | 2019-05-01 | 2 |
Total of all active and inactive participants | 2019-05-01 | 517 |
2018: DUTCH BROS. HEALTH & WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-05-01 | 268 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 411 |
Number of retired or separated participants receiving benefits | 2018-05-01 | 4 |
Total of all active and inactive participants | 2018-05-01 | 415 |
2017: DUTCH BROS. HEALTH & WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-05-01 | 174 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 224 |
Number of retired or separated participants receiving benefits | 2017-05-01 | 1 |
Total of all active and inactive participants | 2017-05-01 | 225 |
2016: DUTCH BROS. HEALTH & WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-05-01 | 124 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 170 |
Number of retired or separated participants receiving benefits | 2016-05-01 | 1 |
Total of all active and inactive participants | 2016-05-01 | 171 |
PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
Policy contract number | 431662 |
Policy instance | 5 |
Insurance contract or identification number | 431662 | Number of Individuals Covered | 523 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $9,605 | Total amount of fees paid to insurance company | USD $2,601 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $86,584 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,605 | Amount paid for insurance broker fees | 2601 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 431660 |
Policy instance | 4 |
Insurance contract or identification number | 431660 | Number of Individuals Covered | 2044 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $7,315 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $269,629 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 7315 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 3 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 12981 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $127,733 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
Policy contract number | GRP00005388 |
Policy instance | 2 |
Insurance contract or identification number | GRP00005388 | Number of Individuals Covered | 1026 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $5,758 | Total amount of fees paid to insurance company | USD $3,676 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $114,976 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,758 | Amount paid for insurance broker fees | 3676 | Additional information about fees paid to insurance broker | BROKER BONUS | Insurance broker organization code? | 3 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 1 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 1622 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $15,678 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $652,433 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $15,678 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 1 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 1226 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $11,819 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $473,610 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,819 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
Policy contract number | GRP00005388 |
Policy instance | 2 |
Insurance contract or identification number | GRP00005388 | Number of Individuals Covered | 756 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,325 | Total amount of fees paid to insurance company | USD $3,676 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $86,508 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,325 | Amount paid for insurance broker fees | 3676 | Additional information about fees paid to insurance broker | BROKER BONUS | Insurance broker organization code? | 3 |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 3 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 12981 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $127,733 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | H8P42 |
Policy instance | 4 |
Insurance contract or identification number | H8P42 | Number of Individuals Covered | 4 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $32 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $421 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 431660 |
Policy instance | 5 |
Insurance contract or identification number | 431660 | Number of Individuals Covered | 1391 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $3,389 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $169,471 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 3389 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
Policy contract number | 431662 |
Policy instance | 6 |
Insurance contract or identification number | 431662 | Number of Individuals Covered | 402 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $8,145 | Total amount of fees paid to insurance company | USD $3,413 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $70,031 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,145 | Amount paid for insurance broker fees | 3413 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BCPK |
Policy instance | 6 |
Insurance contract or identification number | GLUG0BCPK | Number of Individuals Covered | 935 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $13,643 | Total amount of fees paid to insurance company | USD $5,295 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT | Welfare Benefit Premiums Paid to Carrier | USD $259,622 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,912 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | H8P42 |
Policy instance | 5 |
Insurance contract or identification number | H8P42 | Number of Individuals Covered | 4 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $182 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $3,169 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $73 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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RELIANT BEHAVIORAL HEALTH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 15058764 |
Policy instance | 4 |
Insurance contract or identification number | 15058764 | Number of Individuals Covered | 8228 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $92,812 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
Policy contract number | GRP00005388 |
Policy instance | 3 |
Insurance contract or identification number | GRP00005388 | Number of Individuals Covered | 627 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,909 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $63,221 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,646 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 2 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 984 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $10,725 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $418,231 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $5,372 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 ) |
Policy contract number | 10044017 |
Policy instance | 1 |
Insurance contract or identification number | 10044017 | Number of Individuals Covered | 909 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $149,272 | Total amount of fees paid to insurance company | USD $32,760 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | CHIROPRACTIC/ACUPUNCTURE | Welfare Benefit Premiums Paid to Carrier | USD $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 Broker | USD $59,250 | Amount paid for insurance broker fees | 32760 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BCPK |
Policy instance | 6 |
Insurance contract or identification number | GUG 0BCPK | Number of Individuals Covered | 749 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $1,453 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 1453 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BCPK |
Policy instance | 1 |
Insurance contract or identification number | GLTD0BCPK | Number of Individuals Covered | 29 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $217 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 217 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 110863 |
Policy instance | 2 |
Insurance contract or identification number | 110863 | Number of Individuals Covered | 748 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $74,390 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Other welfare benefits provided | CHIROPRACTIC ACUPUNCTURE | Welfare Benefit Premiums Paid to Carrier | USD $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 Broker | USD $74,390 | Insurance broker organization code? | 3 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 3 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 764 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $6,577 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $221,614 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,577 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BCPK |
Policy instance | 4 |
Insurance contract or identification number | GLUG0BCPK | Number of Individuals Covered | 749 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $325 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 325 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BCPK |
Policy instance | 5 |
Insurance contract or identification number | GUDH0BCPK | Number of Individuals Covered | 302 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,970 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | ACCIDENT ONLY VOLUNTARY | Welfare Benefit Premiums Paid to Carrier | USD $29,696 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,970 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BCPK |
Policy instance | 7 |
Insurance contract or identification number | GVTL0BCPK | Number of Individuals Covered | 248 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $4,039 | Total amount of fees paid to insurance company | USD $505 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $18,701 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,039 | Insurance broker organization code? | 5 | Amount paid for insurance broker fees | 505 | Additional information about fees paid to insurance broker | ADMINISTRATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BCPK |
Policy instance | 7 |
Insurance contract or identification number | GVTL0BCPK | Number of Individuals Covered | 195 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $723 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 519 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BCPK |
Policy instance | 1 |
Insurance contract or identification number | GLTD0BCPK | Number of Individuals Covered | 1 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $148 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 74 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 110863 |
Policy instance | 2 |
Insurance contract or identification number | 110863 | Number of Individuals Covered | 242 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $73,026 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | CHIROPRACTIC ACUPUNCTURE | Welfare Benefit Premiums Paid to Carrier | USD $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 Broker | USD $73,026 | Insurance broker organization code? | 3 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 3 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 569 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $6,638 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $221,137 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,638 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BCPK |
Policy instance | 4 |
Insurance contract or identification number | GLUG0BCPK | Number of Individuals Covered | 549 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $466 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 322 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUDH0BCPK |
Policy instance | 5 |
Insurance contract or identification number | GUDH0BCPK | Number of Individuals Covered | 210 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $2,931 | Total amount of fees paid to insurance company | USD $309 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $29,308 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,931 | Amount paid for insurance broker fees | 309 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0BCPK |
Policy instance | 6 |
Insurance contract or identification number | GUG 0BCPK | Number of Individuals Covered | 550 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $2,128 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 1468 | Additional information about fees paid to insurance broker | ADMINISTRATION | Insurance broker organization code? | 5 |
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OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 ) |
Policy contract number | 10010259 |
Policy instance | 3 |
Insurance contract or identification number | 10010259 | Number of Individuals Covered | 368 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $4,778 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $146,692 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 110863 |
Policy instance | 2 |
Insurance contract or identification number | 110863 | Number of Individuals Covered | 241 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $43,077 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | CHIROPRACTIC | Welfare Benefit Premiums Paid to Carrier | USD $1,371,604 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 ) |
Policy contract number | WBT001038 |
Policy instance | 1 |
Insurance contract or identification number | WBT001038 | Number of Individuals Covered | 308 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $5,764 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $80,223 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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