401k Plan data: GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN plan

GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN
Plan identification number	501

GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

GOLDEN BEAR INSURANCE CO. has sponsored the creation of one or more 401k plans.

Company Name: GOLDEN BEAR INSURANCE CO.

Employer identification number (EIN): 942567927

NAIC Classification: 524150

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-06-01

Plan Statistics for GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2022: GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-06-01 112
Total number of active participants reported on line 7a of the Form 5500 2022-06-01 115
Total of all active and inactive participants 2022-06-01 115

Measure	Date	Value
2022: GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-06-01	112
Total number of active participants reported on line 7a of the Form 5500	2022-06-01	115
Total of all active and inactive participants	2022-06-01	115

Form 5500 Responses for GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN

2022: GOLDEN BEAR INSURANCE CO. HEALTH AND WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-06-01	Type of plan entity	Single employer plan
2022-06-01	First time form 5500 has been submitted	Yes
2022-06-01	Submission has been amended	No
2022-06-01	This submission is the final filing	No
2022-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-06-01	Plan is a collectively bargained plan	No
2022-06-01	Plan funding arrangement – Insurance	Yes
2022-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-06-01	Plan benefit arrangement – Insurance	Yes
2022-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10216526

Policy instance

Insurance contract or identification number	10216526
Number of Individuals Covered	115
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,431
Total amount of fees paid to insurance company	USD $187
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $28,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,431
Insurance broker organization code?	3
Amount paid for insurance broker fees	187
Additional information about fees paid to insurance broker	BROKER BONUS

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10216527

Policy instance

Insurance contract or identification number	10216527
Number of Individuals Covered	115
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $2,993
Total amount of fees paid to insurance company	USD $150
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $23,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,993
Insurance broker organization code?	3
Amount paid for insurance broker fees	150
Additional information about fees paid to insurance broker	BROKER BONUS

SUTTER HEALTH AND AETNA INSURANCE (National Association of Insurance Commissioners NAIC id number: 15107 )

Policy contract number

0139906SH

Policy instance

Insurance contract or identification number	0139906SH
Number of Individuals Covered	7
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $60,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0139906

Policy instance

Insurance contract or identification number	0139906
Number of Individuals Covered	102
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $25,176
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $487,994
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,176
Insurance broker organization code?	3

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0139906HNO

Policy instance

Insurance contract or identification number	0139906HNO
Number of Individuals Covered	53
Insurance policy start date	2022-06-01
Insurance policy end date	2023-05-31
Total amount of commissions paid to insurance broker	USD $34,408
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $693,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,408
Insurance broker organization code?	3

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Company Name:	GOLDEN BEAR INSURANCE CO.
Employer identification number (EIN):	942567927
NAIC Classification:	524150