Form 5500 · Employee benefit plan · COBURG, OR
SERENITY LANE
The filing calls this plan SERENITY LANE HEALTHCARE PLAN.
Public Form 5500 records show how SERENITY LANE of COBURG, OR, a health care and social assistance employer, structures its employee benefits. Its broker of record is BENNIE INSURANCE, LLC. Coverage is written through KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST and 3 other carriers. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 93-0606316 · plan 501 · plan year 2025, filed Jul 10, 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.
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 4 insured contracts covering health, dental, vision, life and disability; the largest, with KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST, covers 209 people.
Reported premium across the insured contracts is $1,699,346, with $41,628 in disclosed broker commissions — about 2.4% 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.
BENNIE INSURANCE, LLC is the broker of record on 2 of the 4 contracts; the rest name a different broker or none.
4 carriers appear on the filing, including KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST, UNITED OF OMAHA LIFE INSURANCE COMPANY, WILLAMETTE DENTAL INSURANCE, INC. and VISION SERVICE PLAN. KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST writes the largest contract by premium.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | Health | 209 | Jan 1, 2026 | $1,522,154 | $30,546 |
| UNITED OF OMAHA LIFE INSURANCE COMPANY | Life, Disability | 177 | Jan 1, 2026 | $104,940 | $11,082 |
| WILLAMETTE DENTAL INSURANCE, INC. | Dental | 109 | Jan 1, 2026 | $53,761 | $0 |
| VISION SERVICE PLAN | Vision | 139 | Jan 1, 2026 | $18,491 | $0 |
Premium and claims on this contract
WILLAMETTE DENTAL INSURANCE, INC., contract OR342. For the contract year on this filing, the carrier reported $53,761 in premium earned and $72,965 in claims incurred. Dividing one by the other gives 136%.
- WILLAMETTE DENTAL INSURANCE, INC., contract OR342 reported $6,182 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.
Reported to OSHA
Reported to OSHA for 2025: 226 employees, 2 recordable cases, 16 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
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