Form 5500 · Employee benefit plan · SANTA MONICA, CA
DEVIATION GAMES
The filing calls this plan DEVIATION GAMES LLC HEALTH PLAN.
DEVIATION GAMES of SANTA MONICA, CA files a Form 5500 with the U.S. Department of Labor disclosing its employee benefit plan. Its broker of record is HUB INTERNATIONAL INS SVCS INC. Coverage is written through CALIFORNIA PHYSICIANS SERVICE and 3 other carriers. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 84-3010812 · plan 501 · plan year 2023, filed Mar 24, 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.
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 4 insured contracts covering health, dental, vision, life and disability; the largest, with CALIFORNIA PHYSICIANS SERVICE, covers 127 people.
Reported premium across the insured contracts is $1,320,511, with $33,701 in disclosed broker commissions — about 2.6% of premium.
The most recent policy period ended in December, and the plan year ends December 31. Group contracts typically renew on that annual cycle.
HUB INTERNATIONAL INS SVCS INC is the broker of record on 1 of the 4 contracts; the rest name a different broker or none.
4 carriers appear on the filing, including CALIFORNIA PHYSICIANS SERVICE, KAISER FOUNDATION HEALTH PLAN, INC., DELTA DENTAL OF CALIFORNIA and PRINCIPAL LIFE INSURANCE COMPANY. CALIFORNIA PHYSICIANS SERVICE writes the largest contract by premium.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| KAISER FOUNDATION HEALTH PLAN, INC. | Health | 28 | Jan 1, 2024 | $186,755 | $14,645 |
| DELTA DENTAL OF CALIFORNIA | Dental | 151 | Jan 1, 2024 | $113,357 | $11,336 |
| PRINCIPAL LIFE INSURANCE COMPANY | Vision, Life, Disability | 137 | Jan 1, 2024 | $52,751 | $7,720 |
| CALIFORNIA PHYSICIANS SERVICE | Health | 127 | Jan 1, 2024 | $967,648 | $0 |
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.
How this plan compares
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