Form 5500 · Employee benefit plan · LOS ANGELES, CA
ASCOT HOTEL ANGELENO
The filing calls this plan ASCOT HOTEL ANGELENO HEALTH PLAN.
ASCOT HOTEL ANGELENO of LOS ANGELES, CA is a 100-participant hospitality and food service employer whose group benefits are disclosed in its annual Form 5500 filing. Its broker of record is HUB INTERNATIONAL INS SERVICES INC. Coverage is written through BLUE CROSS OF CALIFORNIA and 2 other carriers. The plan's most recent policy period ended in March.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 26-3861226 · plan 501 · plan year 2025, filed Aug 21, 2025
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How this plan is funded
Fully insured as reported
The filing reports medical coverage through an insurance contract on Schedule A, and no money paid for benefits by the plan itself.
Benefits declared on this filing
Also declared: death benefits, other welfare.
Declared benefits are the plan’s own line 8b codes on Form 5500. “Not on Schedule A” means no insured contract for that line appears on this filing. That usually means the benefit is self-funded, or it sits under a different plan number.
Where a line has more than one insured contract, the carrier and the covered figure are the largest contract's by premium. The contracts are not added up: a pharmacy carve-out and the medical carrier beside it cover the same people.
Persons covered is the count the carrier filed for that policy at the end of its policy year, and it can include dependents. Participants is the plan's own count at the start of its plan year. The two count different people, so a covered figure can be larger.
Plan brief
Schedule A lists 3 insured contracts covering health, dental, vision, life and disability; the largest, with BLUE CROSS OF CALIFORNIA, covers 71 people.
Reported premium across the insured contracts is $608,296, with $33,303 in disclosed broker commissions — about 5.5% of premium.
The health contract's policy period ended in March, while at least one ancillary line's policy period ended in June. The plan is on a split renewal cycle.
HUB INTERNATIONAL INS SERVICES INC is the broker of record on all 3 contracts.
3 carriers appear on the filing, including BLUE CROSS OF CALIFORNIA, ANTHEM LIFE INSURANCE COMPANY and STANDARD INSURANCE COMPANY. BLUE CROSS OF CALIFORNIA writes the largest contract by premium.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| BLUE CROSS OF CALIFORNIA | Health, Dental, Vision | 71 | Apr 1, 2025 | $588,720 | $30,822 |
| ANTHEM LIFE INSURANCE COMPANY | Life, Disability | 107 | Apr 1, 2025 | $13,725 | $1,719 |
| STANDARD INSURANCE COMPANY | Life, Disability | 111 | Jul 1, 2024 | $5,851 | $762 |
Covered = persons covered at policy year end, as filed on Schedule A for that policy — often certificates or one class, not the whole plan. Premium = the filing’s own premium/charges figure; “—” means not credibly reported.
Reported to OSHA
Reported to OSHA for 2025: 84 employees, 4 recordable cases, 0 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
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