401k Plan data: FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN plan

FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN 401k Plan overview

Plan Name	FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN
Plan identification number	501

FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT 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

FIRST CONGREGATIONAL CHURCH OF LOS ANGELES has sponsored the creation of one or more 401k plans.

Company Name: FIRST CONGREGATIONAL CHURCH OF LOS ANGELES

Employer identification number (EIN): 951945255

NAIC Classification: 611000

Additional information about FIRST CONGREGATIONAL CHURCH OF LOS ANGELES

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C0132050

More information about FIRST CONGREGATIONAL CHURCH OF LOS ANGELES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-10-01 SUSAN LEARY 2020-06-03

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2018-10-01	SUSAN LEARY	2020-06-03

Plan Statistics for FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN

401k plan membership statisitcs for FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN

Measure Date Value
2018: FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-10-01 103
Total number of active participants reported on line 7a of the Form 5500 2018-10-01 102
Number of retired or separated participants receiving benefits 2018-10-01 0
Number of other retired or separated participants entitled to future benefits 2018-10-01 0
Total of all active and inactive participants 2018-10-01 102

Measure	Date	Value
2018: FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-10-01	103
Total number of active participants reported on line 7a of the Form 5500	2018-10-01	102
Number of retired or separated participants receiving benefits	2018-10-01	0
Number of other retired or separated participants entitled to future benefits	2018-10-01	0
Total of all active and inactive participants	2018-10-01	102

Form 5500 Responses for FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN

2018: FIRST CONGREGATIONAL CHURCH OF LOS ANGELES DBA PILGRIM SCHOOL WRAP BENEFIT PLAN 2018 form 5500 responses
2018-10-01	Type of plan entity	Single employer plan
2018-10-01	First time form 5500 has been submitted	Yes
2018-10-01	Submission has been amended	No
2018-10-01	This submission is the final filing	No
2018-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-10-01	Plan is a collectively bargained plan	No
2018-10-01	Plan funding arrangement – Insurance	Yes
2018-10-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-10-01	Plan benefit arrangement – Insurance	Yes
2018-10-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

0108598HNO

Policy instance

Insurance contract or identification number	0108598HNO
Number of Individuals Covered	100
Insurance policy start date	2018-11-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $21,404
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 $474,887
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,123
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

0108598

Policy instance

Insurance contract or identification number	0108598
Number of Individuals Covered	7
Insurance policy start date	2018-11-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $1,036
Total amount of fees paid to insurance company	USD $2,550
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 $29,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $207
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

227575

Policy instance

Insurance contract or identification number	227575
Number of Individuals Covered	15
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $3,478
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 $91,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,478
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3342199

Policy instance

Insurance contract or identification number	3342199
Number of Individuals Covered	91
Insurance policy start date	2018-11-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $4,030
Total amount of fees paid to insurance company	USD $1,342
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	Yes
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 $40,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,030
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BFJS

Policy instance

Insurance contract or identification number	G000BFJS
Number of Individuals Covered	116
Insurance policy start date	2018-10-01
Insurance policy end date	2019-09-30
Total amount of commissions paid to insurance broker	USD $2,067
Total amount of fees paid to insurance company	USD $684
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	Yes
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 $13,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,067
Amount paid for insurance broker fees	608
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

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Company Name:	FIRST CONGREGATIONAL CHURCH OF LOS ANGELES
Employer identification number (EIN):	951945255
NAIC Classification:	611000

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0132050