Form 5500 · Employee benefit plan · HUGHSON, CA
HUGHSON SAMARITAN VILLAGE
The filing calls this plan HUGHSON SAMARITAN VILLAGE HEALTH & WELFARE BENEFIT PLAN.
HUGHSON SAMARITAN VILLAGE of HUGHSON, CA insures health, dental, vision and life coverage for its employees, per Schedule A of its Form 5500. Its broker of record is HUB INTERNATIONAL INS SERVICES INC. Coverage is written through KAISER FOUNDATION HEALTH PLAN, INC. and 1 other carrier. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 46-0469127 · plan 501 · plan year 2025, filed Jul 13, 2026
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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.
The filing carries code 4S: this plan is filing again after previously being exempt.
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.
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 2 insured contracts covering health, dental, vision and life; the largest, with KAISER FOUNDATION HEALTH PLAN, INC., covers 63 people.
Reported premium across the insured contracts is $653,325, with $38,960 in disclosed broker commissions — about 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 SERVICES INC is the broker of record on 1 of the 2 contracts; the rest name a different broker or none.
Two carriers split the book: KAISER FOUNDATION HEALTH PLAN, INC. and METROPOLITAN LIFE INSURANCE COMPANY.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| KAISER FOUNDATION HEALTH PLAN, INC. | Health | 63 | Jan 1, 2026 | $570,674 | $25,906 |
| METROPOLITAN LIFE INSURANCE COMPANY | Dental, Vision, Life | 182 | Jan 1, 2026 | $82,651 | $13,054 |
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: 163 employees, 7 recordable cases, 311 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
Other plans filed by this employer
How this plan compares
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