TREASURE ISLAND, LLC has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: TREASURE ISLAND BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-04-01 | 788 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-04-01 | 848 |
| Number of retired or separated participants receiving benefits | 2022-04-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2022-04-01 | 0 |
| Total of all active and inactive participants | 2022-04-01 | 854 |
| 2021: TREASURE ISLAND BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-04-01 | 753 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-04-01 | 1,355 |
| Number of retired or separated participants receiving benefits | 2021-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-04-01 | 0 |
| Total of all active and inactive participants | 2021-04-01 | 1,355 |
| 2020: TREASURE ISLAND BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-04-01 | 2,072 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-04-01 | 818 |
| Number of retired or separated participants receiving benefits | 2020-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-04-01 | 0 |
| Total of all active and inactive participants | 2020-04-01 | 818 |
| Number of employers contributing to the scheme | 2020-04-01 | 0 |
| 2019: TREASURE ISLAND BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-04-01 | 1,471 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 2,072 |
| Number of retired or separated participants receiving benefits | 2019-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-04-01 | 0 |
| Total of all active and inactive participants | 2019-04-01 | 2,072 |
| Number of employers contributing to the scheme | 2019-04-01 | 0 |
| 2018: TREASURE ISLAND BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-04-01 | 1,078 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-04-01 | 1,471 |
| Number of retired or separated participants receiving benefits | 2018-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-04-01 | 0 |
| Total of all active and inactive participants | 2018-04-01 | 1,471 |
| Number of employers contributing to the scheme | 2018-04-01 | 0 |
| 2017: TREASURE ISLAND BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-04-01 | 1,036 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-04-01 | 1,078 |
| Number of retired or separated participants receiving benefits | 2017-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-04-01 | 0 |
| Total of all active and inactive participants | 2017-04-01 | 1,078 |
| Number of employers contributing to the scheme | 2017-04-01 | 0 |
| 2016: TREASURE ISLAND BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-04-01 | 840 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 1,036 |
| Number of retired or separated participants receiving benefits | 2016-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-04-01 | 0 |
| Total of all active and inactive participants | 2016-04-01 | 1,036 |
| 2015: TREASURE ISLAND BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 1,002 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 840 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-04-01 | 0 |
| Total of all active and inactive participants | 2015-04-01 | 840 |
| 2014: TREASURE ISLAND BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 1,096 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 1,002 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-04-01 | 0 |
| Total of all active and inactive participants | 2014-04-01 | 1,002 |
| 2013: TREASURE ISLAND BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 1,125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 1,096 |
| Number of retired or separated participants receiving benefits | 2013-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-04-01 | 0 |
| Total of all active and inactive participants | 2013-04-01 | 1,096 |
| 2012: TREASURE ISLAND BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 2,256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 2,179 |
| Total of all active and inactive participants | 2012-04-01 | 2,179 |
| Total participants | 2012-04-01 | 2,179 |
| 2011: TREASURE ISLAND BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-04-01 | 1,207 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-04-01 | 2,256 |
| Total of all active and inactive participants | 2011-04-01 | 2,256 |
| Total participants | 2011-04-01 | 2,256 |
| 2010: TREASURE ISLAND BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-04-01 | 1,194 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-04-01 | 1,207 |
| Number of retired or separated participants receiving benefits | 2010-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-04-01 | 0 |
| Total of all active and inactive participants | 2010-04-01 | 1,207 |
| Total participants | 2010-04-01 | 1,207 |
| 2009: TREASURE ISLAND BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-04-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-04-01 | 1,194 |
| Number of retired or separated participants receiving benefits | 2009-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-04-01 | 0 |
| Total of all active and inactive participants | 2009-04-01 | 1,194 |
| Total participants | 2009-04-01 | 1,194 |
| 2022: TREASURE ISLAND BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: TREASURE ISLAND BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: TREASURE ISLAND BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: TREASURE ISLAND BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: TREASURE ISLAND BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: TREASURE ISLAND BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: TREASURE ISLAND BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Submission has been amended | No |
| 2016-04-01 | This submission is the final filing | No |
| 2016-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-04-01 | Plan is a collectively bargained plan | No |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: TREASURE ISLAND BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Submission has been amended | No |
| 2015-04-01 | This submission is the final filing | No |
| 2015-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-04-01 | Plan is a collectively bargained plan | No |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: TREASURE ISLAND BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: TREASURE ISLAND BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Submission has been amended | No |
| 2013-04-01 | This submission is the final filing | No |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-04-01 | Plan is a collectively bargained plan | No |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: TREASURE ISLAND BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Submission has been amended | No |
| 2012-04-01 | This submission is the final filing | No |
| 2012-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-04-01 | Plan is a collectively bargained plan | No |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: TREASURE ISLAND BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Submission has been amended | No |
| 2011-04-01 | This submission is the final filing | No |
| 2011-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-04-01 | Plan is a collectively bargained plan | No |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: TREASURE ISLAND BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | Submission has been amended | No |
| 2010-04-01 | This submission is the final filing | No |
| 2010-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-04-01 | Plan is a collectively bargained plan | No |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: TREASURE ISLAND BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | First time form 5500 has been submitted | Yes |
| 2009-04-01 | Submission has been amended | No |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-04-01 | Plan is a collectively bargained plan | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 1 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $900 | | Total amount of fees paid to insurance company | USD $25 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL | | 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 $8,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $526 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS AND FEES | | Insurance broker organization code? | 3 |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | L05303 |
| Policy instance | 4 |
| Insurance contract or identification number | L05303 | | Number of Individuals Covered | 1356 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $13,409 | | 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 $3,043,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,022 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS AND FEES | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 ) |
| Policy contract number | L05303 |
| Policy instance | 3 |
| Insurance contract or identification number | L05303 | | Number of Individuals Covered | 823 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | 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 $3,207,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 52414 ) |
| Policy contract number | 122133 |
| Policy instance | 2 |
| Insurance contract or identification number | 122133 | | Number of Individuals Covered | 1448 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $9,679 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $906,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,679 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS AND FEES | | Insurance broker organization code? | 3 |
|
| INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 ) |
| Policy contract number | 26059 |
| Policy instance | 5 |
| Insurance contract or identification number | 26059 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $136,155 | | 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 $136,454 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $90,670 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISISONS AND FEES | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 231681-231681 |
| Policy instance | 1 |
| Insurance contract or identification number | 231681-231681 | | Number of Individuals Covered | 1741 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | 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 | 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 $1,178,030 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 2 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 27 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $322 | | Total amount of fees paid to insurance company | USD $37 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | LEGAL, AUTO / HOME, PET | | 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 $6,590 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $322 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 37 | | Additional information about fees paid to insurance broker | FEES |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0348700000 |
| Policy instance | 5 |
| Insurance contract or identification number | 0348700000 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $886 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | UNIVERSAL LIFE | | 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 $17,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $620 | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 4 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $26 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | 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 $228 | | 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 | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0348700000 |
| Policy instance | 6 |
| Insurance contract or identification number | 0348700000 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $39 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, CRITICAL ILLNESS | | 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 $350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803242G |
| Policy instance | 7 |
| Insurance contract or identification number | 803242G | | Number of Individuals Covered | 1355 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $13,842 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOL LIFE | | 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 $393,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6394 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70064-9 |
| Policy instance | 3 |
| Insurance contract or identification number | 70064-9 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $15,304 | | Total amount of fees paid to insurance company | USD $1,536 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $64,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,212 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1536 | | Additional information about fees paid to insurance broker | TECHNOLOGY FEE |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 6 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,029 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $719 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70064-9 |
| Policy instance | 5 |
| Insurance contract or identification number | 70064-9 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $14,608 | | Total amount of fees paid to insurance company | USD $2,994 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $42,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,410 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2994 | | Additional information about fees paid to insurance broker | SERVICE FEE |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 231681-231681 |
| Policy instance | 3 |
| Insurance contract or identification number | 231681-231681 | | Number of Individuals Covered | 2182 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,426,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 231681HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 231681HNO | | Number of Individuals Covered | 2164 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,397,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 2 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $4,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803242G |
| Policy instance | 4 |
| Insurance contract or identification number | 803242G | | Number of Individuals Covered | 818 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $61,227 | | Total amount of fees paid to insurance company | USD $899 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $472,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,463 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BONUS |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70064-9 |
| Policy instance | 5 |
| Insurance contract or identification number | 70064-9 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $14,619 | | Total amount of fees paid to insurance company | USD $1,770 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $66,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,619 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SERVICE FEE |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 231681HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 231681HNO | | Number of Individuals Covered | 2693 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $20,645 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,478,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,645 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 2 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $68 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $5,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 68 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 6 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,396 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $996 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803242G |
| Policy instance | 4 |
| Insurance contract or identification number | 803242G | | Number of Individuals Covered | 2072 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $40,406 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $271,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,182 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 231681-0231681 |
| Policy instance | 3 |
| Insurance contract or identification number | 231681-0231681 | | Number of Individuals Covered | 2763 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $83 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,349,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 83 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 2 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $59 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $5,446 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 59 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 231681 |
| Policy instance | 3 |
| Insurance contract or identification number | 231681 | | Number of Individuals Covered | 1628 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $21,378 | | Total amount of fees paid to insurance company | USD $49 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,686,229 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $21,378 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 231681HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 231681HNO | | Number of Individuals Covered | 1471 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,534,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 231681 |
| Policy instance | 7 |
| Insurance contract or identification number | 231681 | | Number of Individuals Covered | 1812 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $91,102 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,402,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,220 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 6 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $6,209 | | Total amount of fees paid to insurance company | USD $0 | | 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT,CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $38,410 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,207 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | 70064-9 |
| Policy instance | 4 |
| Insurance contract or identification number | 70064-9 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $40,190 | | Total amount of fees paid to insurance company | USD $1,200 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $63,039 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,190 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker name | EMPYREAN INSURANCE SERVICES, INC |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
| Policy contract number | 231681HNO |
| Policy instance | 3 |
| Insurance contract or identification number | 231681HNO | | Number of Individuals Covered | 1426 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,113,801 | | 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 | 9788 |
| Policy instance | 2 |
| Insurance contract or identification number | 9788 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $1,128 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $551 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | TAMMY A. SWAIN |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 ) |
| Policy contract number | 195612 |
| Policy instance | 1 |
| Insurance contract or identification number | 195612 | | Number of Individuals Covered | 711 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $99,207 | | 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 $4,279,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $99,207 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | BQT73 |
| Policy instance | 5 |
| Insurance contract or identification number | BQT73 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $1,886 | | 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 | 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 $16,477 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $430 | | Insurance broker organization code? | 3 | | Insurance broker name | ERIN K. RADA |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 4 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | No | | 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 | LEGAL | | 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 $5,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 3 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 466 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $74,848 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS CANCER | | 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 $185,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,615 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 195612/977050 |
| Policy instance | 2 |
| Insurance contract or identification number | 195612/977050 | | Number of Individuals Covered | 1719 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $101,382 | | 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 | 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 $3,225,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $101,382 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 ) |
| Policy contract number | 195612 |
| Policy instance | 6 |
| Insurance contract or identification number | 195612 | | Number of Individuals Covered | 840 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $4,655 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $200,649 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,655 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 348700000 |
| Policy instance | 6 |
| Insurance contract or identification number | 348700000 | | Number of Individuals Covered | 391 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $116,672 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS CANCER | | 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 $147,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77,011 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 9788 |
| Policy instance | 4 |
| Insurance contract or identification number | 9788 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $6,894 | | 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 | No | | 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 | VOLUNTARY 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 $29,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,525 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 3 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 1002 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $20,734 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $206,473 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,734 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 195612/977050 |
| Policy instance | 2 |
| Insurance contract or identification number | 195612/977050 | | Number of Individuals Covered | 1750 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $109,109 | | 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 | 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 $3,266,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $109,109 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 ) |
| Policy contract number | 195612 |
| Policy instance | 1 |
| Insurance contract or identification number | 195612 | | Number of Individuals Covered | 1068 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $85,276 | | 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 $3,317,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $85,276 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 5 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | No | | 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 | LEGAL | | 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 $5,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 195612 |
| Policy instance | 2 |
| Insurance contract or identification number | 195612 | | Number of Individuals Covered | 800 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $49,953 | | Total amount of fees paid to insurance company | USD $51 | | 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 $2,345,794 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,851 | | Amount paid for insurance broker fees | 51 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1500856 |
| Policy instance | 6 |
| Insurance contract or identification number | 1500856 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $587 | | 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 | No | | 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 | LEGAL | | 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 $5,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $587 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER FOY AND ASSOC INS. SVCS., INC |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 9788 |
| Policy instance | 5 |
| Insurance contract or identification number | 9788 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $11,078 | | 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 | No | | 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 | VOLUNTARY 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 $33,219 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,008 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9813841 |
| Policy instance | 4 |
| Insurance contract or identification number | 9813841 | | Number of Individuals Covered | 2030 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $2,112 | | 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 $65,821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,112 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER FOY AND ASSOC INS. SVCS., INC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 228145/200187 |
| Policy instance | 3 |
| Insurance contract or identification number | 228145/200187 | | Number of Individuals Covered | 1095 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $67,249 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $1,066,277 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,684 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 95473 ) |
| Policy contract number | 195612 |
| Policy instance | 1 |
| Insurance contract or identification number | 195612 | | Number of Individuals Covered | 1216 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $51,433 | | Total amount of fees paid to insurance company | USD $53 | | 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 $2,415,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,706 | | Amount paid for insurance broker fees | 53 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9813841 |
| Policy instance | 1 |
| Insurance contract or identification number | 9813841 | | Number of Individuals Covered | 2179 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,105 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 2 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 1137 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $11,760 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $123,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,760 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 4 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $13,305 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $103,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,305 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
|
| HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
| Policy contract number | 60000621 |
| Policy instance | 5 |
| Insurance contract or identification number | 60000621 | | Number of Individuals Covered | 2164 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $233,600 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,054,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $233,600 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3334535 |
| Policy instance | 6 |
| Insurance contract or identification number | 3334535 | | Number of Individuals Covered | 1046 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $49,112 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $596,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,112 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 3 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 416 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $19,903 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,903 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 5 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $26,399 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $202,959 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 4 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $16,681 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $128,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 3 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 1171 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $14,371 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 3334535 |
| Policy instance | 2 |
| Insurance contract or identification number | 3334535 | | Number of Individuals Covered | 1084 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $56,107 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $570,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 ) |
| Policy contract number | 9813841 |
| Policy instance | 1 |
| Insurance contract or identification number | 9813841 | | Number of Individuals Covered | 2253 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $3,203 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $76,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
| Policy contract number | 60000621 |
| Policy instance | 6 |
| Insurance contract or identification number | 60000621 | | Number of Individuals Covered | 2256 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $193,521 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,925,499 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 7564 |
| Policy instance | 4 |
| Insurance contract or identification number | 7564 | | Number of Individuals Covered | 2315 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $3,347 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,347 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 200187 |
| Policy instance | 3 |
| Insurance contract or identification number | 200187 | | Number of Individuals Covered | 1207 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $19,370 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $144,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,370 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
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| HEALTH PLAN OF NEVADA (National Association of Insurance Commissioners NAIC id number: 96342 ) |
| Policy contract number | 60000621 |
| Policy instance | 1 |
| Insurance contract or identification number | 60000621 | | Number of Individuals Covered | 2228 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $213,098 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,829,136 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $213,098 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
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| PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 ) |
| Policy contract number | 11097 |
| Policy instance | 2 |
| Insurance contract or identification number | 11097 | | Number of Individuals Covered | 2226 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $65,344 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $603,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,344 | | Insurance broker organization code? | 3 | | Insurance broker name | PETER C. FOY & ASSOCIATES |
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