Form 5500 · Employee benefit plan · TUALATIN, OR
BOARD OF TRUSTEES, UFCW LOCAL 555-EMPLOYERS HEALTH
The filing calls this plan UFCW LOCAL 555-EMPLOYERS HEALTH TRUST.
BOARD OF TRUSTEES, UFCW LOCAL 555-EMPLOYERS HEALTH of TUALATIN, OR insures health, dental, vision and life coverage for its employees, per Schedule A of its Form 5500. Coverage is written through LIFEMAP ASSURANCE COMPANY and 5 other carriers. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 23-7017278 · plan 501 · plan year 2025, filed Apr 14, 2026
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How this plan is funded
Both, as reported
The medical insurance contracts on the filing cover fewer than half the people in the plan, so the rest is paid another way.
A stop-loss policy appears on a Form 5500 only when the plan itself is the beneficiary, or the premiums are paid from plan money. Many employers buy stop-loss and never report it here. So a plan with no stop-loss on its filing may still have it.
Benefits declared on this filing
Health: the largest of the 3 insured health contracts, with REGENCE BLUECROSS BLUESHIELD OF OREGON, covers 429 of 11,818 participants (3.6%) on Schedule A.
Vision: the largest of the 2 insured vision contracts, with REGENCE BLUECROSS BLUESHIELD OF OREGON, covers 429 of 11,818 participants (3.6%) on Schedule A.
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 6 insured contracts covering health, dental, vision and life.
The filing declares health, dental, vision, life and disability. Disability appears with no insured contract on Schedule A. That coverage may be self-funded, or placed with a carrier that is not on this filing.
Reported premium is $2,130,517; the filing discloses no broker commission on these contracts.
The health contract's policy period ended in December, while at least one ancillary line's policy period ended in June. The plan is on a split renewal cycle.
No broker of record is named on the Schedule A. The contracts may be written directly with the carrier, or the broker fields were left blank on the filing.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| LIFEMAP ASSURANCE COMPANY | Dental | 2,488 | Jan 1, 2025 | $1,161,034 | $0 |
| REGENCE BLUECROSS BLUESHIELD OF OREGON | Health, Dental, Vision | 429 | Jan 1, 2025 | $630,593 | $0 |
| PROVIDENCE HEALTH PLAN | Health | 20 | Jul 1, 2025 | $123,731 | $0 |
| VISION SERVICE PLAN | Vision | 8,367 | Jul 1, 2025 | $80,557 | $0 |
| STANDARD INSURANCE COMPANY | Life | 9,490 | Jul 1, 2025 | $74,059 | $0 |
| UNITEDHEALTHCARE OF OREGON, INC. | Health | 11 | Jan 1, 2025 | $60,543 | $0 |
Premium and claims on this contract
STANDARD INSURANCE COMPANY, contract 612432. For the contract year on this filing, the carrier reported $68,550 in premium earned and $34,211 in claims incurred. Dividing one by the other gives 50%.
- STANDARD INSURANCE COMPANY, contract 612432 reported $34,342 in retention.
Retention is what the carrier kept of the premium after claims, as reported: administration, commissions and other charges.
Only experience-rated contracts report these figures, so most filings leave them blank.
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.
Administrator and service providers
The plan administrator is from line 3a of the main form. The service providers are named on Schedule C of this filing. We publish company names only.
Money the plan held and paid out
Sourced from U.S. DOL EFAST2 Form 5500 · Schedule H
These are the plan's own figures from Schedule H, the financial statement it files. They are not the premium on Schedule A.
How this plan compares
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