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SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 401k Plan overview

Plan NameSWEDA COMPANY, LLC WELFARE BENEFIT PLAN
Plan identification number 501

SWEDA COMPANY, LLC WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

SWEDA COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name:SWEDA COMPANY, LLC
Employer identification number (EIN):954603872
NAIC Classification:334110

Additional information about SWEDA COMPANY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 2672537

More information about SWEDA COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SWEDA COMPANY, LLC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-03-01GASTON LAZARTE2023-07-13 GASTON LAZARTE2023-07-13
5012021-03-01GASTON LAZARTE2022-08-11 GASTON LAZARTE2022-08-11
5012020-03-01NANCY GRATTAN2021-08-11
5012019-03-01NANCY GRATTAN2020-08-17
5012018-03-01NANCY GRATTAN2019-09-11
5012018-02-01
5012017-02-01
5012016-02-01
5012015-02-01NANCY GRATTAN
5012014-02-01NANCY GRATTAN
5012013-02-01NANCY GRATTAN
5012012-02-01GABRIELLE FLORES GABRIELLE FLORES2013-08-26
5012011-02-01RUBY LEM
5012010-02-01RUBY LEM
5012009-02-01RUBY LEM

Plan Statistics for SWEDA COMPANY, LLC WELFARE BENEFIT PLAN

401k plan membership statisitcs for SWEDA COMPANY, LLC WELFARE BENEFIT PLAN

Measure Date Value
2022: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-03-01184
Total number of active participants reported on line 7a of the Form 55002022-03-0165
Number of retired or separated participants receiving benefits2022-03-010
Number of other retired or separated participants entitled to future benefits2022-03-010
Total of all active and inactive participants2022-03-0165
2021: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-03-01154
Total number of active participants reported on line 7a of the Form 55002021-03-01184
Number of retired or separated participants receiving benefits2021-03-010
Number of other retired or separated participants entitled to future benefits2021-03-010
Total of all active and inactive participants2021-03-01184
2020: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-03-01213
Total number of active participants reported on line 7a of the Form 55002020-03-01154
Number of retired or separated participants receiving benefits2020-03-010
Number of other retired or separated participants entitled to future benefits2020-03-010
Total of all active and inactive participants2020-03-01154
Number of employers contributing to the scheme2020-03-010
2019: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-03-01214
Total number of active participants reported on line 7a of the Form 55002019-03-01213
Number of retired or separated participants receiving benefits2019-03-010
Number of other retired or separated participants entitled to future benefits2019-03-010
Total of all active and inactive participants2019-03-01213
Number of employers contributing to the scheme2019-03-010
2018: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01202
Total number of active participants reported on line 7a of the Form 55002018-03-01214
Number of retired or separated participants receiving benefits2018-03-010
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01214
Number of employers contributing to the scheme2018-03-010
Total participants, beginning-of-year2018-02-01223
Total number of active participants reported on line 7a of the Form 55002018-02-01202
Number of retired or separated participants receiving benefits2018-02-010
Number of other retired or separated participants entitled to future benefits2018-02-010
Total of all active and inactive participants2018-02-01202
2017: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-02-01186
Total number of active participants reported on line 7a of the Form 55002017-02-01223
Number of retired or separated participants receiving benefits2017-02-010
Number of other retired or separated participants entitled to future benefits2017-02-010
Total of all active and inactive participants2017-02-01223
2016: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-01196
Total number of active participants reported on line 7a of the Form 55002016-02-01186
Number of retired or separated participants receiving benefits2016-02-010
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-01186
2015: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-02-01174
Total number of active participants reported on line 7a of the Form 55002015-02-01181
Number of retired or separated participants receiving benefits2015-02-010
Number of other retired or separated participants entitled to future benefits2015-02-010
Total of all active and inactive participants2015-02-01181
2014: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-02-01183
Total number of active participants reported on line 7a of the Form 55002014-02-01174
Number of retired or separated participants receiving benefits2014-02-010
Number of other retired or separated participants entitled to future benefits2014-02-010
Total of all active and inactive participants2014-02-01174
2013: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-02-01194
Total number of active participants reported on line 7a of the Form 55002013-02-01183
Number of retired or separated participants receiving benefits2013-02-010
Number of other retired or separated participants entitled to future benefits2013-02-010
Total of all active and inactive participants2013-02-01183
2012: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-02-01223
Total number of active participants reported on line 7a of the Form 55002012-02-01191
Number of retired or separated participants receiving benefits2012-02-013
Number of other retired or separated participants entitled to future benefits2012-02-010
Total of all active and inactive participants2012-02-01194
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-02-010
Total participants2012-02-01194
2011: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-02-01277
Total number of active participants reported on line 7a of the Form 55002011-02-01277
Number of retired or separated participants receiving benefits2011-02-014
Number of other retired or separated participants entitled to future benefits2011-02-010
Total of all active and inactive participants2011-02-01281
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2011-02-010
2010: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-02-01263
Total number of active participants reported on line 7a of the Form 55002010-02-01263
Number of retired or separated participants receiving benefits2010-02-011
Number of other retired or separated participants entitled to future benefits2010-02-010
Total of all active and inactive participants2010-02-01264
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2010-02-010
2009: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-02-01263
Total number of active participants reported on line 7a of the Form 55002009-02-01263
Number of retired or separated participants receiving benefits2009-02-0113
Number of other retired or separated participants entitled to future benefits2009-02-010
Total of all active and inactive participants2009-02-01276
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-02-010
Total participants2009-02-01276

Form 5500 Responses for SWEDA COMPANY, LLC WELFARE BENEFIT PLAN

2022: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-03-01Type of plan entitySingle employer plan
2022-03-01Submission has been amendedNo
2022-03-01This submission is the final filingNo
2022-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-03-01Plan is a collectively bargained planNo
2022-03-01Plan funding arrangement – InsuranceYes
2022-03-01Plan benefit arrangement – InsuranceYes
2021: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-03-01Type of plan entitySingle employer plan
2021-03-01Submission has been amendedNo
2021-03-01This submission is the final filingNo
2021-03-01This return/report is a short plan year return/report (less than 12 months)No
2021-03-01Plan is a collectively bargained planNo
2021-03-01Plan funding arrangement – InsuranceYes
2021-03-01Plan benefit arrangement – InsuranceYes
2020: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01Type of plan entitySingle employer plan
2020-03-01Plan funding arrangement – InsuranceYes
2020-03-01Plan benefit arrangement – InsuranceYes
2019: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01Type of plan entitySingle employer plan
2019-03-01Plan funding arrangement – InsuranceYes
2019-03-01Plan benefit arrangement – InsuranceYes
2018: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – InsuranceYes
2018-02-01Type of plan entitySingle employer plan
2018-02-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-02-01Plan funding arrangement – InsuranceYes
2018-02-01Plan benefit arrangement – InsuranceYes
2017: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-02-01Type of plan entitySingle employer plan
2017-02-01Plan funding arrangement – InsuranceYes
2017-02-01Plan benefit arrangement – InsuranceYes
2016: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan benefit arrangement – InsuranceYes
2015: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-02-01Type of plan entitySingle employer plan
2015-02-01Submission has been amendedNo
2015-02-01This submission is the final filingNo
2015-02-01This return/report is a short plan year return/report (less than 12 months)No
2015-02-01Plan is a collectively bargained planNo
2015-02-01Plan funding arrangement – InsuranceYes
2015-02-01Plan benefit arrangement – InsuranceYes
2014: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-02-01Type of plan entitySingle employer plan
2014-02-01Submission has been amendedNo
2014-02-01This submission is the final filingNo
2014-02-01This return/report is a short plan year return/report (less than 12 months)No
2014-02-01Plan is a collectively bargained planNo
2014-02-01Plan funding arrangement – InsuranceYes
2014-02-01Plan benefit arrangement – InsuranceYes
2013: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-02-01Type of plan entitySingle employer plan
2013-02-01Submission has been amendedNo
2013-02-01This submission is the final filingNo
2013-02-01This return/report is a short plan year return/report (less than 12 months)No
2013-02-01Plan is a collectively bargained planNo
2013-02-01Plan funding arrangement – InsuranceYes
2013-02-01Plan benefit arrangement – InsuranceYes
2012: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-02-01Type of plan entitySingle employer plan
2012-02-01Submission has been amendedNo
2012-02-01This submission is the final filingNo
2012-02-01This return/report is a short plan year return/report (less than 12 months)No
2012-02-01Plan is a collectively bargained planNo
2012-02-01Plan funding arrangement – InsuranceYes
2012-02-01Plan benefit arrangement – InsuranceYes
2011: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-02-01Type of plan entitySingle employer plan
2011-02-01Submission has been amendedNo
2011-02-01This submission is the final filingNo
2011-02-01This return/report is a short plan year return/report (less than 12 months)No
2011-02-01Plan is a collectively bargained planNo
2011-02-01Plan funding arrangement – InsuranceYes
2011-02-01Plan benefit arrangement – InsuranceYes
2010: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-02-01Type of plan entitySingle employer plan
2010-02-01Submission has been amendedNo
2010-02-01This submission is the final filingNo
2010-02-01This return/report is a short plan year return/report (less than 12 months)No
2010-02-01Plan is a collectively bargained planNo
2010-02-01Plan funding arrangement – InsuranceYes
2010-02-01Plan benefit arrangement – InsuranceYes
2009: SWEDA COMPANY, LLC WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-02-01Type of plan entitySingle employer plan
2009-02-01Submission has been amendedNo
2009-02-01This submission is the final filingNo
2009-02-01This return/report is a short plan year return/report (less than 12 months)No
2009-02-01Plan is a collectively bargained planNo
2009-02-01Plan funding arrangement – InsuranceYes
2009-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000940220528
Policy instance 5
Insurance contract or identification number000940220528
Number of Individuals Covered0
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $294
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $178
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000940220529
Policy instance 4
Insurance contract or identification number000940220529
Number of Individuals Covered0
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $132
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedWEEKLY INCOME
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number00000000
Policy instance 3
Insurance contract or identification number00000000
Number of Individuals Covered65
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $39,127
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $632,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,758
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BBLK
Policy instance 2
Insurance contract or identification numberG000BBLK
Number of Individuals Covered9
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $480
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT ONLY VOLUNTRY, CRITICAL ILLNESS VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $293
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 1
Insurance contract or identification number233498
Number of Individuals Covered19
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,753
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $132,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,123
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BBLK
Policy instance 3
Insurance contract or identification numberG000BBLK
Number of Individuals Covered9
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $414
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $414
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BBLK
Policy instance 4
Insurance contract or identification numberG000BBLK
Number of Individuals Covered6
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $183
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $183
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BBLK
Policy instance 5
Insurance contract or identification numberG000BBLK
Number of Individuals Covered3
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $191
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $191
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BBLK
Policy instance 6
Insurance contract or identification numberG000BBLK
Number of Individuals Covered12
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $268
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $268
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 2
Insurance contract or identification number233498
Number of Individuals Covered30
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $8,103
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $179,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,103
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered184
Insurance policy start date2021-03-01
Insurance policy end date2022-02-28
Total amount of commissions paid to insurance brokerUSD $52,064
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $928,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,064
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 2
Insurance contract or identification number233498
Number of Individuals Covered38
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $12,701
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $231,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,701
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered160
Insurance policy start date2020-03-01
Insurance policy end date2021-02-28
Total amount of commissions paid to insurance brokerUSD $51,171
Total amount of fees paid to insurance companyUSD $1,214
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $862,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,171
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 2
Insurance contract or identification number233498
Number of Individuals Covered45
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $10,812
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $237,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,812
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered221
Insurance policy start date2019-03-01
Insurance policy end date2020-02-29
Total amount of commissions paid to insurance brokerUSD $63,373
Total amount of fees paid to insurance companyUSD $1,229
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,034,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63,373
Amount paid for insurance broker fees1229
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered222
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $66,121
Total amount of fees paid to insurance companyUSD $2,207
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,102,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,978
Amount paid for insurance broker fees2207
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 2
Insurance contract or identification number233498
Number of Individuals Covered28
Insurance policy start date2018-03-01
Insurance policy end date2019-02-28
Total amount of commissions paid to insurance brokerUSD $7,219
Total amount of fees paid to insurance companyUSD $427
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $145,971
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,219
Amount paid for insurance broker fees427
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233498
Policy instance 2
Insurance contract or identification number233498
Number of Individuals Covered11
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $4,058
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $80,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,058
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameTOLMAN AND WIKER INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered202
Insurance policy start date2017-03-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $68,299
Total amount of fees paid to insurance companyUSD $3,821
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,203,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,299
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameTOLMAN & WIKER INSURANCE SERVICES
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number166518
Policy instance 1
Insurance contract or identification number166518
Number of Individuals Covered258
Insurance policy start date2016-03-01
Insurance policy end date2017-02-28
Total amount of commissions paid to insurance brokerUSD $63,506
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,364,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63,506
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameTOLMAN AND WIKER INS. SVCS., LLC

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