MEWA-ECE Form
This Form is Open to Public Inspection
OMB No. 1210-0116
Department of Labor
Employee Benefits Security Administration
Complete as applicable:
02/01/2016
Land O'Lakes, Inc. Member Cooperative Health Plan
PO Box 64101
MS4098
St. Paul, MN 55164
(651) 481-2222
46-2631103
601
Governing Board of the Land O'Lakes, Inc. Member Cooperative Health Plan
Attn: Pamela Grove
PO Box 64101
MS4098
St. Paul, MN 55164
(651) 375-2167
pjgrove@landolakes.com
Land O'Lakes, Inc.
PO Box 64101
St. Paul, MN 55164
41-0365145
Land O'Lakes, Inc.
Attn: Pamela Grove
PO Box 64101
MS4098
St. Paul, MN 55164
(651) 481-2222
pjgrove@landolakes.com
see attachment
see attachment
n/a
n/a
n/a
Milliman, Inc.
Attn: Jessica Butterworth
1301 Fifth Avenue
Suite 3800
Seattle, WA 98101
(206) 504-5714
jessica.butterworth@milliman.com
91-0675641
n/a
Governing Board of the Land O'Lakes, Inc. Member Cooperative Health Plan
Attn: Pamela Grove
PO Box 64101
MS4098
St. Paul, MN 55164
(651) 375-2167
pjgrove@landolakes.com
n/a
No
Yes
Federal Insurance Company
Yes
Yes
If no, please explain.
No
If yes, please identify each litigation or enforcement proceeding to include (if applicable): (1) the case number, (2) the date, (3) the nature of the proceedings, (4) the court, (5) all parties (for example, plaintiffs and defendants or petitioners and respondents), and (6) the disposition.
No
If yes, please explain.
No
Entity | Year |
---|
17a | 17b | 17c | 17d | 17e | 17f | 17g | 17h | 17i | 17j |
---|---|---|---|---|---|---|---|---|---|
Enter all States where the MEWA or ECE is operating. | Is coverage provided? | State registration number. | Name of state agent or entity for service of process. | Is the entity a licensed health insurer in this State? | If yes to 17e, enter NAIC number. | If no to 17e, is the entity fully insured? | If yes to 17g, enter name and NAIC number of insurer. | Does the entity purchase stop loss coverage? | If yes to 17i, enter the name and NAIC number of insurer. |
TN
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
TX
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
UT
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
VA
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
WA
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
WI
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
WY
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
AK
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
AL
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
AR
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
CA
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
CO
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
DE
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
IA
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
ID
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
IL
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
IN
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
KS
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
KY
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
LA
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
MI
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
MN
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
MO
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
MS
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
MT
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
ND
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
NE
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
OH
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
OK
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
OR
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
PA
Is new? |
No | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No | ||||
SD
Is new? |
Yes | No | Yes | Blue Cross and Blue Shield of MN, 55206 | No |
WI,MN
5183
N/A
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Under penalty of perjury and other penalties set forth in the instructions, I declare that I have examined this report, including any accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury and other penalties set forth in the instructions, I also declare that, unless this is an extension request, this report is complete.