401k Plan data: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN plan

PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN
Plan identification number	505

PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

PACIFIC COMPENSATION INSURANCE COMPANY has sponsored the creation of one or more 401k plans.

Company Name: PACIFIC COMPENSATION INSURANCE COMPANY

Employer identification number (EIN): 020635701

NAIC Classification: 524150

Additional information about PACIFIC COMPENSATION INSURANCE COMPANY

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 2002-01-31

Company Identification Number: C2375278

Legal Registered Office Address: 300 S Grand Ave Ste 2600

Los Angeles
United States of America (USA)
90071

More information about PACIFIC COMPENSATION INSURANCE COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2018-01-01 LORENA BUCHOLTZ
505 2017-01-01 LORENA BUCHOLTZ
505 2016-05-01 LORENA BUCHOLTZ LORENA BUCHOLTZ 2017-07-24
505 2015-05-01 TERESA SMILEY
505 2014-05-01 TERESA SMILEY
505 2013-05-01 DENISE RICHARDSON
505 2012-05-01 JUNE DUXLER
505 2011-05-01 BARRY COHN
505 2010-05-01 BARRY COHN
505 2009-05-01 JUNE DUXLER

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
505	2018-01-01	LORENA BUCHOLTZ
505	2017-01-01	LORENA BUCHOLTZ
505	2016-05-01	LORENA BUCHOLTZ	LORENA BUCHOLTZ	2017-07-24
505	2015-05-01	TERESA SMILEY
505	2014-05-01	TERESA SMILEY
505	2013-05-01	DENISE RICHARDSON
505	2012-05-01	JUNE DUXLER
505	2011-05-01	BARRY COHN
505	2010-05-01	BARRY COHN
505	2009-05-01	JUNE DUXLER

Plan Statistics for PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN

Measure Date Value
2018: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 133
Number of retired or separated participants receiving benefits 2018-01-01 1
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 134
2017: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 118
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 119
2016: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-05-01 151
Total number of active participants reported on line 7a of the Form 5500 2016-05-01 147
Number of retired or separated participants receiving benefits 2016-05-01 1
Number of other retired or separated participants entitled to future benefits 2016-05-01 0
Total of all active and inactive participants 2016-05-01 148
2015: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-05-01 154
Total number of active participants reported on line 7a of the Form 5500 2015-05-01 148
Number of retired or separated participants receiving benefits 2015-05-01 3
Number of other retired or separated participants entitled to future benefits 2015-05-01 0
Total of all active and inactive participants 2015-05-01 151
2014: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-05-01 155
Total number of active participants reported on line 7a of the Form 5500 2014-05-01 150
Number of retired or separated participants receiving benefits 2014-05-01 4
Number of other retired or separated participants entitled to future benefits 2014-05-01 0
Total of all active and inactive participants 2014-05-01 154
2013: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-05-01 174
Total number of active participants reported on line 7a of the Form 5500 2013-05-01 149
Number of retired or separated participants receiving benefits 2013-05-01 6
Number of other retired or separated participants entitled to future benefits 2013-05-01 0
Total of all active and inactive participants 2013-05-01 155
2012: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-05-01 135
Total number of active participants reported on line 7a of the Form 5500 2012-05-01 151
Number of retired or separated participants receiving benefits 2012-05-01 23
Number of other retired or separated participants entitled to future benefits 2012-05-01 0
Total of all active and inactive participants 2012-05-01 174
2011: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-05-01 140
Total number of active participants reported on line 7a of the Form 5500 2011-05-01 132
Number of retired or separated participants receiving benefits 2011-05-01 3
Number of other retired or separated participants entitled to future benefits 2011-05-01 0
Total of all active and inactive participants 2011-05-01 135
2010: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-05-01 160
Total number of active participants reported on line 7a of the Form 5500 2010-05-01 140
Number of retired or separated participants receiving benefits 2010-05-01 14
Number of other retired or separated participants entitled to future benefits 2010-05-01 0
Total of all active and inactive participants 2010-05-01 154
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-05-01 0
Total participants 2010-05-01 154
2009: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-05-01 160
Total number of active participants reported on line 7a of the Form 5500 2009-05-01 160
Number of retired or separated participants receiving benefits 2009-05-01 0
Number of other retired or separated participants entitled to future benefits 2009-05-01 0
Total of all active and inactive participants 2009-05-01 160
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-05-01 0
Total participants 2009-05-01 160

Measure	Date	Value
2018: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	133
Number of retired or separated participants receiving benefits	2018-01-01	1
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	134
2017: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	118
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	119
2016: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-05-01	151
Total number of active participants reported on line 7a of the Form 5500	2016-05-01	147
Number of retired or separated participants receiving benefits	2016-05-01	1
Number of other retired or separated participants entitled to future benefits	2016-05-01	0
Total of all active and inactive participants	2016-05-01	148
2015: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-05-01	154
Total number of active participants reported on line 7a of the Form 5500	2015-05-01	148
Number of retired or separated participants receiving benefits	2015-05-01	3
Number of other retired or separated participants entitled to future benefits	2015-05-01	0
Total of all active and inactive participants	2015-05-01	151
2014: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-05-01	155
Total number of active participants reported on line 7a of the Form 5500	2014-05-01	150
Number of retired or separated participants receiving benefits	2014-05-01	4
Number of other retired or separated participants entitled to future benefits	2014-05-01	0
Total of all active and inactive participants	2014-05-01	154
2013: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-05-01	174
Total number of active participants reported on line 7a of the Form 5500	2013-05-01	149
Number of retired or separated participants receiving benefits	2013-05-01	6
Number of other retired or separated participants entitled to future benefits	2013-05-01	0
Total of all active and inactive participants	2013-05-01	155
2012: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-05-01	135
Total number of active participants reported on line 7a of the Form 5500	2012-05-01	151
Number of retired or separated participants receiving benefits	2012-05-01	23
Number of other retired or separated participants entitled to future benefits	2012-05-01	0
Total of all active and inactive participants	2012-05-01	174
2011: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-05-01	140
Total number of active participants reported on line 7a of the Form 5500	2011-05-01	132
Number of retired or separated participants receiving benefits	2011-05-01	3
Number of other retired or separated participants entitled to future benefits	2011-05-01	0
Total of all active and inactive participants	2011-05-01	135
2010: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-05-01	160
Total number of active participants reported on line 7a of the Form 5500	2010-05-01	140
Number of retired or separated participants receiving benefits	2010-05-01	14
Number of other retired or separated participants entitled to future benefits	2010-05-01	0
Total of all active and inactive participants	2010-05-01	154
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-05-01	0
Total participants	2010-05-01	154
2009: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-05-01	160
Total number of active participants reported on line 7a of the Form 5500	2009-05-01	160
Number of retired or separated participants receiving benefits	2009-05-01	0
Number of other retired or separated participants entitled to future benefits	2009-05-01	0
Total of all active and inactive participants	2009-05-01	160
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-05-01	0
Total participants	2009-05-01	160

Form 5500 Responses for PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN

2018: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-05-01	Type of plan entity	Single employer plan
2016-05-01	Submission has been amended	No
2016-05-01	This submission is the final filing	No
2016-05-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-05-01	Plan is a collectively bargained plan	No
2016-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-05-01	Plan benefit arrangement – Insurance	Yes
2015: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-05-01	Type of plan entity	Single employer plan
2015-05-01	Submission has been amended	No
2015-05-01	This submission is the final filing	No
2015-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-05-01	Plan is a collectively bargained plan	No
2015-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-05-01	Plan benefit arrangement – Insurance	Yes
2014: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-05-01	Type of plan entity	Single employer plan
2014-05-01	Submission has been amended	No
2014-05-01	This submission is the final filing	No
2014-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-05-01	Plan is a collectively bargained plan	No
2014-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-05-01	Plan benefit arrangement – Insurance	Yes
2013: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-05-01	Type of plan entity	Single employer plan
2013-05-01	Submission has been amended	No
2013-05-01	This submission is the final filing	No
2013-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-05-01	Plan is a collectively bargained plan	No
2013-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-05-01	Plan benefit arrangement – Insurance	Yes
2012: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-05-01	Type of plan entity	Single employer plan
2012-05-01	Submission has been amended	No
2012-05-01	This submission is the final filing	No
2012-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-05-01	Plan is a collectively bargained plan	No
2012-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-05-01	Plan benefit arrangement – Insurance	Yes
2011: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-05-01	Type of plan entity	Single employer plan
2011-05-01	Submission has been amended	No
2011-05-01	This submission is the final filing	No
2011-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-05-01	Plan is a collectively bargained plan	No
2011-05-01	Plan funding arrangement – Insurance	Yes
2011-05-01	Plan benefit arrangement – Insurance	Yes
2010: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2010 form 5500 responses
2010-05-01	Type of plan entity	Single employer plan
2010-05-01	Submission has been amended	No
2010-05-01	This submission is the final filing	No
2010-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-05-01	Plan is a collectively bargained plan	No
2010-05-01	Plan funding arrangement – Insurance	Yes
2010-05-01	Plan benefit arrangement – Insurance	Yes
2009: PACIFIC COMPENSATION INSURANCE COMPANY EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-05-01	Type of plan entity	Single employer plan
2009-05-01	First time form 5500 has been submitted	Yes
2009-05-01	Submission has been amended	No
2009-05-01	This submission is the final filing	No
2009-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-05-01	Plan is a collectively bargained plan	No
2009-05-01	Plan funding arrangement – Insurance	Yes
2009-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0760936

Policy instance

Insurance contract or identification number	0760936
Number of Individuals Covered	283
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $24,585
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $568,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,113
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	151
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,720
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $63,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,131
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	67
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $15,140
Total amount of fees paid to insurance company	USD $118
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	GCIEE, GRPACCVO AND GRPHSPVO, GROUP LONG-TERM CARE
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 $102,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,562
Insurance broker organization code?	3
Amount paid for insurance broker fees	118
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	232
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $134,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	68
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	125
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $30,433
Total amount of fees paid to insurance company	USD $1,278
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 $703,158
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,910
Amount paid for insurance broker fees	1278
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	132
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $11,398
Total amount of fees paid to insurance company	USD $106
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	GCIEE, GRPACCVO AND GRPHSPVO, GROUP LONG-TERM CARE
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $78,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,124
Insurance broker organization code?	3
Amount paid for insurance broker fees	106
Additional information about fees paid to insurance broker	FEES
Insurance broker name	HUB INTERNATIONAL OF CA INS SVCS

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	222
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $126,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	80
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
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	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $10,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

6644227

Policy instance

Insurance contract or identification number	6644227
Number of Individuals Covered	6
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $16
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	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 $105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL OF CA INS. SVC

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	128
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $28,291
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 $641,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,291
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL OF CA INS SVC

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0760936

Policy instance

Insurance contract or identification number	0760936
Number of Individuals Covered	281
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $19,857
Total amount of fees paid to insurance company	USD $5,810
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $488,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,857
Amount paid for insurance broker fees	5810
Additional information about fees paid to insurance broker	INCENTIVE
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVC

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

0760936HNO

Policy instance

Insurance contract or identification number	0760936HNO
Number of Individuals Covered	107
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $23,576
Total amount of fees paid to insurance company	USD $10,000
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
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 $614,801
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,576
Amount paid for insurance broker fees	10000
Additional information about fees paid to insurance broker	SALES INITIATIVE
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVC

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

MULTIPLE

Policy instance

Insurance contract or identification number	MULTIPLE
Number of Individuals Covered	146
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,146
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	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 $59,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,146
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SVC, INC.

PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )

Policy contract number

6644227

Policy instance

Insurance contract or identification number	6644227
Number of Individuals Covered	20
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $298
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $298
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0ASGI

Policy instance

Insurance contract or identification number	GLUG0ASGI
Number of Individuals Covered	148
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $6,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC 0ASGI

Policy instance

Insurance contract or identification number	GUC 0ASGI
Number of Individuals Covered	36
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $1,958
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,958
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0ASGI

Policy instance

Insurance contract or identification number	GLTD0ASGI
Number of Individuals Covered	148
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
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	Yes
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 $27,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	113
Insurance policy start date	2015-05-01
Insurance policy end date	2015-04-30
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	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $109,124
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0ASGI

Policy instance

Insurance contract or identification number	GVTL0ASGI
Number of Individuals Covered	67
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $3,899
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	ACCIDENTAL DEATH & 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 $25,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,899
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	134
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $27,520
Total amount of fees paid to insurance company	USD $310
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 $574,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,520
Amount paid for insurance broker fees	310
Additional information about fees paid to insurance broker	BONUS COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	144
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-28
Total amount of commissions paid to insurance broker	USD $9,838
Total amount of fees paid to insurance company	USD $1,101
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	GROUP AND INDIVIDUAL LONG-TERM CARE
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 $65,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,838
Insurance broker organization code?	3
Amount paid for insurance broker fees	1101
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	125
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $644
Total amount of fees paid to insurance company	USD $24
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 $15,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $644
Amount paid for insurance broker fees	12
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS INC.

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	26
Insurance policy start date	2015-05-01
Insurance policy end date	2015-04-30
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	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $7,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	67
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $42,760
Total amount of fees paid to insurance company	USD $1,611
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,060,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,760
Amount paid for insurance broker fees	820
Additional information about fees paid to insurance broker	BONUS, OVERRIDE AND NON MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	INTERCARE INSURANCE SOLUTIONS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0ASGI

Policy instance

Insurance contract or identification number	GLUG0ASGI
Number of Individuals Covered	150
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $6,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	76
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $45,162
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,091,577
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,162
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUC 0ASGI

Policy instance

Insurance contract or identification number	GUC 0ASGI
Number of Individuals Covered	35
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $2,245
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	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $14,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,245
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	131
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $26,325
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 $548,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,035
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	29
Insurance policy start date	2014-05-01
Insurance policy end date	2014-04-30
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	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $8,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )

Policy contract number

907142

Policy instance

Insurance contract or identification number	907142
Number of Individuals Covered	112
Insurance policy start date	2014-05-01
Insurance policy end date	2014-04-30
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	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $115,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0ASGI

Policy instance

Insurance contract or identification number	GLTD0ASGI
Number of Individuals Covered	150
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
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	Yes
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 $27,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	131
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $694
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 $16,770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $694
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0ASGI

Policy instance

Insurance contract or identification number	GVTL0ASGI
Number of Individuals Covered	66
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $4,268
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	ACCIDENTAL DEATH & 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 $28,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,268
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	146
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $9,675
Total amount of fees paid to insurance company	USD $1,290
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	GROUP AND INDIVIDUAL LONG-TERM CARE
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 $64,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,675
Amount paid for insurance broker fees	115
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	128
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $24,967
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 $520,544
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,967
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	149
Insurance policy start date	2013-03-01
Insurance policy end date	2014-02-28
Total amount of commissions paid to insurance broker	USD $10,079
Total amount of fees paid to insurance company	USD $109
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	GROUP AND INDIVIDUAL LONG-TERM CARE
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 $67,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,854
Amount paid for insurance broker fees	109
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	RGEB, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	149
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $5,881
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	Yes
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 $39,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,397
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	131
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $709
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 $17,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $709
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	81
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $45,840
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,119,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,840
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	149
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $4,147
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	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	ACCIDENTAL DEATH & 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 $36,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,824
Insurance broker organization code?	3
Insurance broker name	HUB INTERNATIONAL INS. SERVICES

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1018473

Policy instance

Insurance contract or identification number	1018473
Number of Individuals Covered	264
Insurance policy start date	2013-05-01
Insurance policy end date	2014-04-30
Total amount of commissions paid to insurance broker	USD $1,020
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $149,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,020
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	138
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $858
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 $20,392
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $858
Insurance broker organization code?	3
Insurance broker name	RGEB, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	151
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $6,850
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	Yes
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 $45,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,289
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	151
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $5,185
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	ACCIDENTAL DEATH & 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 $34,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,759
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	151
Insurance policy start date	2012-03-01
Insurance policy end date	2013-02-28
Total amount of commissions paid to insurance broker	USD $10,119
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	GROUP AND INDIVIDUAL LONG-TERM CARE
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 $67,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,119
Insurance broker organization code?	3
Insurance broker name	RGEB, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	92
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $49,537
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,177,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,537
Insurance broker organization code?	3
Insurance broker name	RGEB, INC.

CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

002034

Policy instance

Insurance contract or identification number	002034
Number of Individuals Covered	26
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $1,018
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $11,052
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $931
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1018473

Policy instance

Insurance contract or identification number	1018473
Number of Individuals Covered	244
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $5,443
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $137,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,105
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	107
Insurance policy start date	2012-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $20,915
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 $401,266
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,155
Insurance broker organization code?	3
Insurance broker name	GNW-EVERGREEN INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	151
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $9,463
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	GROUP AND INDIVIDUAL LONG-TERM CARE
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 $63,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	149
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $10,885
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	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $72,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

G0360

Policy instance

Insurance contract or identification number	G0360
Number of Individuals Covered	136
Insurance policy start date	2011-05-01
Insurance policy end date	2013-04-30
Total amount of commissions paid to insurance broker	USD $58,114
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $1,250,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	101
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $17,266
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 $326,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1018473

Policy instance

Insurance contract or identification number	1018473
Number of Individuals Covered	246
Insurance policy start date	2011-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $4,795
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $116,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

275845

Policy instance

Insurance contract or identification number	275845
Number of Individuals Covered	101
Insurance policy start date	2010-05-01
Insurance policy end date	2012-04-30
Total amount of commissions paid to insurance broker	USD $58,805
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,275,912
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9718792

Policy instance

Insurance contract or identification number	9718792
Number of Individuals Covered	346
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,207
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,381
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

949213

Policy instance

Insurance contract or identification number	949213
Number of Individuals Covered	146
Insurance policy start date	2010-03-01
Insurance policy end date	2011-03-01
Total amount of commissions paid to insurance broker	USD $9,861
Total amount of fees paid to insurance company	USD $455
Life Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Other welfare benefits provided	LONG-TERM CARE INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $65,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00446954

Policy instance

Insurance contract or identification number	00446954
Number of Individuals Covered	140
Insurance policy start date	2010-05-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $14,060
Total amount of fees paid to insurance company	USD $2,089
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,601
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

262681

Policy instance

Insurance contract or identification number	262681
Number of Individuals Covered	85
Insurance policy start date	2010-05-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $13,970
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $303,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

008363

Policy instance

Insurance contract or identification number	008363
Number of Individuals Covered	145
Insurance policy start date	2010-05-01
Insurance policy end date	2011-04-30
Total amount of commissions paid to insurance broker	USD $10,068
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $67,121
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

PACIFIC COMPENSATION CORPORATION 401K PLAN [EIN = 010560965]

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Company Name:	PACIFIC COMPENSATION INSURANCE COMPANY
Employer identification number (EIN):	020635701
NAIC Classification:	524150

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	2002-01-31
Company Identification Number:	C2375278
Legal Registered Office Address:	300 S Grand Ave Ste 2600 Los Angeles United States of America (USA) 90071