CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN
Plan identification number	502

CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

CASA DE LAS CAMPANAS has sponsored the creation of one or more 401k plans.

Company Name:	CASA DE LAS CAMPANAS
Employer identification number (EIN):	330371280
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2022-08-01
502	2021-08-01
502	2020-08-01
502	2019-08-01
502	2018-08-01
502	2017-08-01	GINGER LYON
502	2016-08-01	GINGER LYON
502	2015-08-01	GINGER LYON
502	2014-08-01	GINGER LYON
502	2013-08-01	GINGER LYON
502	2012-08-01	GINGER LYON		GINGER LYON	2014-02-10
502	2011-08-01	GINGER LYON
502	2009-08-01			GINGER LYON	2011-02-18
502	2009-08-01	GINGER LYON

Plan Statistics for CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN

401k plan membership statisitcs for CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN

Measure	Date	Value
2022: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-08-01	190
Total number of active participants reported on line 7a of the Form 5500	2022-08-01	194
Number of retired or separated participants receiving benefits	2022-08-01	7
Number of other retired or separated participants entitled to future benefits	2022-08-01	0
Total of all active and inactive participants	2022-08-01	201
2021: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-08-01	212
Total number of active participants reported on line 7a of the Form 5500	2021-08-01	186
Number of retired or separated participants receiving benefits	2021-08-01	4
Number of other retired or separated participants entitled to future benefits	2021-08-01	0
Total of all active and inactive participants	2021-08-01	190
2020: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-08-01	215
Total number of active participants reported on line 7a of the Form 5500	2020-08-01	210
Number of retired or separated participants receiving benefits	2020-08-01	2
Number of other retired or separated participants entitled to future benefits	2020-08-01	0
Total of all active and inactive participants	2020-08-01	212
2019: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-08-01	243
Total number of active participants reported on line 7a of the Form 5500	2019-08-01	213
Number of retired or separated participants receiving benefits	2019-08-01	2
Number of other retired or separated participants entitled to future benefits	2019-08-01	0
Total of all active and inactive participants	2019-08-01	215
2018: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-08-01	255
Total number of active participants reported on line 7a of the Form 5500	2018-08-01	242
Number of retired or separated participants receiving benefits	2018-08-01	1
Number of other retired or separated participants entitled to future benefits	2018-08-01	0
Total of all active and inactive participants	2018-08-01	243
2017: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-08-01	267
Total number of active participants reported on line 7a of the Form 5500	2017-08-01	253
Number of retired or separated participants receiving benefits	2017-08-01	2
Number of other retired or separated participants entitled to future benefits	2017-08-01	0
Total of all active and inactive participants	2017-08-01	255
2016: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-08-01	262
Total number of active participants reported on line 7a of the Form 5500	2016-08-01	267
Number of retired or separated participants receiving benefits	2016-08-01	0
Number of other retired or separated participants entitled to future benefits	2016-08-01	0
Total of all active and inactive participants	2016-08-01	267
2015: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	247
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	261
Number of retired or separated participants receiving benefits	2015-08-01	1
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	262
2014: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	247
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	247
Number of retired or separated participants receiving benefits	2014-08-01	0
Number of other retired or separated participants entitled to future benefits	2014-08-01	0
Total of all active and inactive participants	2014-08-01	247
2013: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-08-01	257
Total number of active participants reported on line 7a of the Form 5500	2013-08-01	244
Number of retired or separated participants receiving benefits	2013-08-01	3
Number of other retired or separated participants entitled to future benefits	2013-08-01	0
Total of all active and inactive participants	2013-08-01	247
2012: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-08-01	257
Total number of active participants reported on line 7a of the Form 5500	2012-08-01	253
Number of retired or separated participants receiving benefits	2012-08-01	4
Number of other retired or separated participants entitled to future benefits	2012-08-01	0
Total of all active and inactive participants	2012-08-01	257
2011: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-08-01	228
Total number of active participants reported on line 7a of the Form 5500	2011-08-01	255
Number of retired or separated participants receiving benefits	2011-08-01	2
Number of other retired or separated participants entitled to future benefits	2011-08-01	0
Total of all active and inactive participants	2011-08-01	257
2009: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-08-01	255
Total number of active participants reported on line 7a of the Form 5500	2009-08-01	236
Number of retired or separated participants receiving benefits	2009-08-01	3
Number of other retired or separated participants entitled to future benefits	2009-08-01	0
Total of all active and inactive participants	2009-08-01	239

Form 5500 Responses for CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN

2022: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-08-01	Type of plan entity	Single employer plan
2022-08-01	Submission has been amended	No
2022-08-01	This submission is the final filing	No
2022-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-08-01	Plan is a collectively bargained plan	No
2022-08-01	Plan funding arrangement – Insurance	Yes
2022-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-08-01	Plan benefit arrangement – Insurance	Yes
2022-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-08-01	Type of plan entity	Single employer plan
2021-08-01	Submission has been amended	No
2021-08-01	This submission is the final filing	No
2021-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-08-01	Plan is a collectively bargained plan	No
2021-08-01	Plan funding arrangement – Insurance	Yes
2021-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-08-01	Plan benefit arrangement – Insurance	Yes
2021-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-08-01	Type of plan entity	Single employer plan
2020-08-01	Submission has been amended	No
2020-08-01	This submission is the final filing	No
2020-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-08-01	Plan is a collectively bargained plan	No
2020-08-01	Plan funding arrangement – Insurance	Yes
2020-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-08-01	Plan benefit arrangement – Insurance	Yes
2020-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-08-01	Type of plan entity	Single employer plan
2019-08-01	Submission has been amended	No
2019-08-01	This submission is the final filing	No
2019-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-08-01	Plan is a collectively bargained plan	No
2019-08-01	Plan funding arrangement – Insurance	Yes
2019-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-08-01	Plan benefit arrangement – Insurance	Yes
2019-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-08-01	Type of plan entity	Single employer plan
2018-08-01	Submission has been amended	No
2018-08-01	This submission is the final filing	No
2018-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-08-01	Plan is a collectively bargained plan	No
2018-08-01	Plan funding arrangement – Insurance	Yes
2018-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-08-01	Plan benefit arrangement – Insurance	Yes
2018-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-08-01	Type of plan entity	Single employer plan
2017-08-01	Submission has been amended	No
2017-08-01	This submission is the final filing	No
2017-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-08-01	Plan is a collectively bargained plan	No
2017-08-01	Plan funding arrangement – Insurance	Yes
2017-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-08-01	Plan benefit arrangement – Insurance	Yes
2017-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-08-01	Type of plan entity	Single employer plan
2016-08-01	Submission has been amended	No
2016-08-01	This submission is the final filing	No
2016-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-08-01	Plan is a collectively bargained plan	No
2016-08-01	Plan funding arrangement – Insurance	Yes
2016-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-08-01	Plan benefit arrangement – Insurance	Yes
2016-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Submission has been amended	No
2014-08-01	This submission is the final filing	No
2014-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-08-01	Plan is a collectively bargained plan	No
2014-08-01	Plan funding arrangement – Insurance	Yes
2014-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2014-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-08-01	Type of plan entity	Single employer plan
2013-08-01	Submission has been amended	No
2013-08-01	This submission is the final filing	No
2013-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-08-01	Plan is a collectively bargained plan	No
2013-08-01	Plan funding arrangement – Insurance	Yes
2013-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-08-01	Plan benefit arrangement – Insurance	Yes
2013-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-08-01	Type of plan entity	Single employer plan
2012-08-01	Submission has been amended	No
2012-08-01	This submission is the final filing	No
2012-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-08-01	Plan is a collectively bargained plan	No
2012-08-01	Plan funding arrangement – Insurance	Yes
2012-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-08-01	Plan benefit arrangement – Insurance	Yes
2012-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-08-01	Type of plan entity	Single employer plan
2011-08-01	Submission has been amended	No
2011-08-01	This submission is the final filing	No
2011-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-08-01	Plan is a collectively bargained plan	No
2011-08-01	Plan funding arrangement – Insurance	Yes
2011-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-08-01	Plan benefit arrangement – Insurance	Yes
2011-08-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: CASA DE LAS CAMPANAS WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-08-01	Type of plan entity	Single employer plan
2009-08-01	Submission has been amended	No
2009-08-01	This submission is the final filing	No
2009-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-08-01	Plan is a collectively bargained plan	No
2009-08-01	Plan funding arrangement – Insurance	Yes
2009-08-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-08-01	Plan benefit arrangement – Insurance	Yes
2009-08-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3016151
Policy instance	3
Insurance contract or identification number E3016151 Number of Individuals Covered 1 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $86 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS AND WORKSITE BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,438 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $86 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	1
Insurance contract or identification number 9791195 Number of Individuals Covered 116 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $841 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,432 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $841 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	2
Insurance contract or identification number 132170 Number of Individuals Covered 95 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $49,328 Total amount of fees paid to insurance company USD $1 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,057,826 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $49,328 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626/9626
Policy instance	9
Insurance contract or identification number 626/9626 Number of Individuals Covered 16 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $3,700 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $53,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,700 Insurance broker organization code? 3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	1004074
Policy instance	4
Insurance contract or identification number 1004074 Number of Individuals Covered 69 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $22,441 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $561,036 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,441 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	894237G
Policy instance	5
Insurance contract or identification number 894237G Number of Individuals Covered 193 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $2,182 Total amount of fees paid to insurance company USD $1,173 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $46,427 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,182 Amount paid for insurance broker fees 1173 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	6
Insurance contract or identification number 12620 Number of Individuals Covered 19 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $1,613 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,522 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,613 Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	7
Insurance contract or identification number 892826 Number of Individuals Covered 28 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $642 Total amount of fees paid to insurance company USD $60 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $642 Amount paid for insurance broker fees 60 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	8
Insurance contract or identification number 892826 Number of Individuals Covered 94 Insurance policy start date 2022-08-01 Insurance policy end date 2023-07-31 Total amount of commissions paid to insurance broker USD $6,776 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $68,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $6,776 Insurance broker organization code? 3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	1004074
Policy instance	1
Insurance contract or identification number 1004074 Number of Individuals Covered 56 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $20,268 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $506,692 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,268 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	2
Insurance contract or identification number 892826 Number of Individuals Covered 97 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $8,279 Total amount of fees paid to insurance company USD $735 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $82,692 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,279 Amount paid for insurance broker fees 735 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	3
Insurance contract or identification number 9791195 Number of Individuals Covered 127 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $960 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,587 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $960 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	894237G
Policy instance	4
Insurance contract or identification number 894237G Number of Individuals Covered 185 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $2,005 Total amount of fees paid to insurance company USD $746 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $42,651 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,005 Amount paid for insurance broker fees 746 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	6
Insurance contract or identification number 132170 Number of Individuals Covered 134 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $37,620 Total amount of fees paid to insurance company USD $788 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184,211 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,620 Amount paid for insurance broker fees 788 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	7
Insurance contract or identification number 892826 Number of Individuals Covered 28 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $642 Total amount of fees paid to insurance company USD $60 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,417 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $642 Amount paid for insurance broker fees 60 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3016151
Policy instance	8
Insurance contract or identification number E3016151 Number of Individuals Covered 1 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $102 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS AND WORKSITE BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,356 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $102 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	5
Insurance contract or identification number 12620 Number of Individuals Covered 19 Insurance policy start date 2021-08-01 Insurance policy end date 2022-07-31 Total amount of commissions paid to insurance broker USD $2,479 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,251 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,479 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	1
Insurance contract or identification number 9791195 Number of Individuals Covered 150 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $1,057 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,507 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,057 Insurance broker organization code? 3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	8
Insurance contract or identification number 626 Number of Individuals Covered 35 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $8,112 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $115,882 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,112 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	3
Insurance contract or identification number 892826 Number of Individuals Covered 112 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $9,716 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $97,323 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,716 Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	4
Insurance contract or identification number 892826 Number of Individuals Covered 34 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $765 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,702 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $765 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	5
Insurance contract or identification number 132170 Number of Individuals Covered 182 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $53,075 Total amount of fees paid to insurance company USD $2,360 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,294,500 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,075 Amount paid for insurance broker fees 2360 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3016151
Policy instance	6
Insurance contract or identification number E3016151 Number of Individuals Covered 1 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $120 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS AND WORKSITE BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,027 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $120 Insurance broker organization code? 3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	1004074
Policy instance	7
Insurance contract or identification number 1004074 Number of Individuals Covered 50 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $20,927 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $523,181 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,927 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	9
Insurance contract or identification number 12620 Number of Individuals Covered 160 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $2,234 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,018 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,234 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	2
Insurance contract or identification number 417376 Number of Individuals Covered 215 Insurance policy start date 2020-08-01 Insurance policy end date 2021-07-31 Total amount of commissions paid to insurance broker USD $2,693 Total amount of fees paid to insurance company USD $1,134 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $61,515 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,693 Amount paid for insurance broker fees 1134 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	7
Insurance contract or identification number 9791195 Number of Individuals Covered 164 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $1,130 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,314 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,130 Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	8
Insurance contract or identification number 892826 Number of Individuals Covered 143 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $10,876 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,608 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,876 Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3016151
Policy instance	6
Insurance contract or identification number E3016151 Number of Individuals Covered 2 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $192 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS AND WORKSITE BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,915 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $192 Insurance broker organization code? 3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	5
Insurance contract or identification number 626 Number of Individuals Covered 53 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $9,195 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $131,362 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,195 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	4
Insurance contract or identification number 132170 Number of Individuals Covered 198 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $53,478 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,303,666 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,478 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	3
Insurance contract or identification number 417376 Number of Individuals Covered 239 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $2,867 Total amount of fees paid to insurance company USD $1,207 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $60,353 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,867 Amount paid for insurance broker fees 1207 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	2
Insurance contract or identification number 892826 Number of Individuals Covered 32 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $582 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,894 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $582 Insurance broker organization code? 3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	1004074
Policy instance	1
Insurance contract or identification number 1004074 Number of Individuals Covered 61 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $16,859 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $421,470 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,859 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	9
Insurance contract or identification number 12620 Number of Individuals Covered 159 Insurance policy start date 2019-08-01 Insurance policy end date 2020-07-31 Total amount of commissions paid to insurance broker USD $11,416 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,416 Insurance broker organization code? 3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	1
Insurance contract or identification number 892826 Number of Individuals Covered 40 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $977 Total amount of fees paid to insurance company USD $111 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,797 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $977 Amount paid for insurance broker fees 111 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	9
Insurance contract or identification number 626 Number of Individuals Covered 53 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $8,299 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $118,558 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,299 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	8
Insurance contract or identification number 132170 Number of Individuals Covered 204 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $54,947 Total amount of fees paid to insurance company USD $661 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,339,206 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,947 Amount paid for insurance broker fees 661 Additional information about fees paid to insurance broker BONUS AND NON-MONETARY COMPENSATION Insurance broker organization code? 3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract number	E3016151
Policy instance	7
Insurance contract or identification number E3016151 Number of Individuals Covered 2 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $257 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided CRITICAL ILLNESS AND WORKSITE BENEFITS Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,387 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $257 Insurance broker organization code? 3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	6
Insurance contract or identification number 417376 Number of Individuals Covered 241 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $2,704 Total amount of fees paid to insurance company USD $1,138 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $56,917 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,704 Amount paid for insurance broker fees 1138 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	5
Insurance contract or identification number 892826 Number of Individuals Covered 133 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $10,993 Total amount of fees paid to insurance company USD $1,105 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $110,105 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,993 Amount paid for insurance broker fees 1105 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	4
Insurance contract or identification number 12620 Number of Individuals Covered 156 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $5,309 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,309 Insurance broker organization code? 3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	1004074
Policy instance	3
Insurance contract or identification number 1004074 Number of Individuals Covered 56 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $18,633 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $465,832 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,633 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	2
Insurance contract or identification number 9791195 Number of Individuals Covered 163 Insurance policy start date 2018-08-01 Insurance policy end date 2019-07-31 Total amount of commissions paid to insurance broker USD $1,174 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,581 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,174 Insurance broker organization code? 3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	7
Insurance contract or identification number 626 Number of Individuals Covered 54 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $8,265 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $118,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	8
Insurance contract or identification number 9791195 Number of Individuals Covered 187 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $1,387 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,026 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	6
Insurance contract or identification number 12620 Number of Individuals Covered 117 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $2,885 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,360 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	5
Insurance contract or identification number 892826 Number of Individuals Covered 137 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $10,259 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $111,649 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	4
Insurance contract or identification number 417376 Number of Individuals Covered 243 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $2,598 Total amount of fees paid to insurance company USD $1,303 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $54,683 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	3
Insurance contract or identification number 132170 Number of Individuals Covered 202 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $49,717 Total amount of fees paid to insurance company USD $2,083 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,215,493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	445060
Policy instance	2
Insurance contract or identification number 445060 Number of Individuals Covered 62 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $20,912 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $464,707 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	1
Insurance contract or identification number 892826 Number of Individuals Covered 43 Insurance policy start date 2017-08-01 Insurance policy end date 2018-07-31 Total amount of commissions paid to insurance broker USD $1,209 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,956 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	0202057
Policy instance	8
Insurance contract or identification number 0202057 Number of Individuals Covered 38 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $1,055 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,540 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,055 Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	7
Insurance contract or identification number 12620 Number of Individuals Covered 95 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $4,994 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $25,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,994 Insurance broker organization code? 3 Insurance broker name CONTINENTAL AMERICAN - SEE ATTACHED
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	6
Insurance contract or identification number 132170 Number of Individuals Covered 227 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $54,413 Total amount of fees paid to insurance company USD $442 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,327,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $54,413 Amount paid for insurance broker fees 442 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0202055
Policy instance	1
Insurance contract or identification number 0202055 Number of Individuals Covered 151 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $10,521 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $113,849 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,521 Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	5
Insurance contract or identification number 9791195 Number of Individuals Covered 200 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $1,233 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,426 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,233 Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	4
Insurance contract or identification number 417376 Number of Individuals Covered 261 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $2,227 Total amount of fees paid to insurance company USD $938 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $46,635 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,227 Amount paid for insurance broker fees 938 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	445060
Policy instance	3
Insurance contract or identification number 445060 Number of Individuals Covered 47 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $15,629 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $347,319 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,629 Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	2
Insurance contract or identification number 626 Number of Individuals Covered 66 Insurance policy start date 2015-08-01 Insurance policy end date 2016-07-31 Total amount of commissions paid to insurance broker USD $8,733 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $124,757 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,733 Insurance broker organization code? 3 Insurance broker name MARSH & MCLENNAN AGENCY LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0202055
Policy instance	7
Insurance contract or identification number 0202055 Number of Individuals Covered 149 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $10,765 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,633 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,765 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	6
Insurance contract or identification number 12620 Number of Individuals Covered 86 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $3,176 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $21,772 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,176 Insurance broker organization code? 3 Insurance broker name CONTINENTAL AMERICAN - SEE ATTACHED
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	5
Insurance contract or identification number 132170 Number of Individuals Covered 209 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $46,302 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,128,806 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,302 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	4
Insurance contract or identification number 626 Number of Individuals Covered 74 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $7,948 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $113,540 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,948 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	2
Insurance contract or identification number 9791195 Number of Individuals Covered 178 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $1,181 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,980 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,181 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	417376
Policy instance	3
Insurance contract or identification number 417376 Number of Individuals Covered 251 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $2,153 Total amount of fees paid to insurance company USD $2,266 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $45,316 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,153 Amount paid for insurance broker fees 2266 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	445060
Policy instance	8
Insurance contract or identification number 445060 Number of Individuals Covered 45 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $12,769 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $283,760 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,769 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	0202057
Policy instance	1
Insurance contract or identification number 0202057 Number of Individuals Covered 37 Insurance policy start date 2014-08-01 Insurance policy end date 2015-07-31 Total amount of commissions paid to insurance broker USD $1,115 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,459 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,115 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	8
Insurance contract or identification number 12620 Number of Individuals Covered 68 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $8,436 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,376 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,728 Insurance broker organization code? 3 Insurance broker name DEBORAH J CARMICHAEL
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	6
Insurance contract or identification number 626 Number of Individuals Covered 59 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $5,383 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $78,536 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,383 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	7
Insurance contract or identification number 9791195 Number of Individuals Covered 166 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $838 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $838 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	421860
Policy instance	3
Insurance contract or identification number 421860 Number of Individuals Covered 41 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $13,333 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $296,298 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,333 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	2
Insurance contract or identification number 132170 Number of Individuals Covered 212 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $46,235 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,129,686 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,235 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	04326
Policy instance	1
Insurance contract or identification number 04326 Number of Individuals Covered 244 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $2,369 Total amount of fees paid to insurance company USD $2,866 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $49,885 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,369 Amount paid for insurance broker fees 967 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3 Insurance broker name AXA ASSISTANCE, USA
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	0202057
Policy instance	4
Insurance contract or identification number 0202057 Number of Individuals Covered 36 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $1,234 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,120 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,234 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0202055
Policy instance	5
Insurance contract or identification number 0202055 Number of Individuals Covered 145 Insurance policy start date 2013-08-01 Insurance policy end date 2014-07-31 Total amount of commissions paid to insurance broker USD $10,839 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,199 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,839 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	2
Insurance contract or identification number 626 Number of Individuals Covered 50 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $5,070 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $72,425 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,070 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	3
Insurance contract or identification number 892826 Number of Individuals Covered 30 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $829 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,292 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $829 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	04326
Policy instance	4
Insurance contract or identification number 04326 Number of Individuals Covered 229 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $2,228 Total amount of fees paid to insurance company USD $2,767 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $46,900 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,228 Amount paid for insurance broker fees 912 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSIONS Insurance broker organization code? 3 Insurance broker name AXA ASSISTANCE, USA
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	5
Insurance contract or identification number 132170 Number of Individuals Covered 207 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $41,963 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,023,444 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $41,963 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	421860
Policy instance	6
Insurance contract or identification number 421860 Number of Individuals Covered 57 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $14,621 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $324,902 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,621 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	8
Insurance contract or identification number 9791195 Number of Individuals Covered 161 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $1,051 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $10,514 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,051 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	7
Insurance contract or identification number 892826 Number of Individuals Covered 149 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $11,315 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $113,049 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,315 Insurance broker organization code? 3 Insurance broker name BARNEY & BARNEY, LLC
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	12620
Policy instance	1
Insurance contract or identification number 12620 Number of Individuals Covered 64 Insurance policy start date 2012-08-01 Insurance policy end date 2013-07-31 Total amount of commissions paid to insurance broker USD $14,441 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $23,808 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,685 Insurance broker organization code? 3 Insurance broker name DEBORAH J CARMICHAEL
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	892826
Policy instance	4
Insurance contract or identification number 892826 Number of Individuals Covered 146 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $10,168 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $101,922 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	7
Insurance contract or identification number 892826 Number of Individuals Covered 35 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $912 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,042 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	6
Insurance contract or identification number 626 Number of Individuals Covered 45 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $4,257 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $60,815 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	421860
Policy instance	5
Insurance contract or identification number 421860 Number of Individuals Covered 43 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $13,702 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $304,478 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	2
Insurance contract or identification number 9791195 Number of Individuals Covered 184 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $1,378 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,780 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	04326
Policy instance	1
Insurance contract or identification number 04326 Number of Individuals Covered 226 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $2,087 Total amount of fees paid to insurance company USD $2,721 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $43,941 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	3
Insurance contract or identification number 132170 Number of Individuals Covered 120 Insurance policy start date 2011-08-01 Insurance policy end date 2012-07-31 Total amount of commissions paid to insurance broker USD $43,385 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $947,087 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	626
Policy instance	1
Insurance contract or identification number 626 Number of Individuals Covered 34 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $3,528 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $50,401 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	132170
Policy instance	2
Insurance contract or identification number 132170 Number of Individuals Covered 133 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $40,246 Total amount of fees paid to insurance company USD $239 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $952,592 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9791195
Policy instance	3
Insurance contract or identification number 9791195 Number of Individuals Covered 224 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $1,295 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $12,949
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	0202055
Policy instance	4
Insurance contract or identification number 0202055 Number of Individuals Covered 151 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $11,147 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	04326
Policy instance	6
Insurance contract or identification number 04326 Number of Individuals Covered 226 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $2,309 Total amount of fees paid to insurance company USD $1,745 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D AND EAP Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $48,614 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number	421860
Policy instance	5
Insurance contract or identification number 421860 Number of Individuals Covered 52 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $14,368 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided MENTAL HEALTH & CHEMICAL DEPENDENCY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $319,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	892826
Policy instance	7
Insurance contract or identification number 892826 Number of Individuals Covered 35 Insurance policy start date 2010-08-01 Insurance policy end date 2011-07-31 Total amount of commissions paid to insurance broker USD $952 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $9,463 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No

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