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EQUITABLE RETIREE HEALTH PLAN 401k Plan overview

Plan NameEQUITABLE RETIREE HEALTH PLAN
Plan identification number 502

EQUITABLE RETIREE HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Dental
  • Vision

401k Sponsoring company profile

EQUITABLE FINANCIAL LIFE INSURANCE COMPANY has sponsored the creation of one or more 401k plans.

Company Name:EQUITABLE FINANCIAL LIFE INSURANCE COMPANY
Employer identification number (EIN):135570651
NAIC Classification:524140

Additional information about EQUITABLE FINANCIAL LIFE INSURANCE COMPANY

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: C0000479

More information about EQUITABLE FINANCIAL LIFE INSURANCE COMPANY

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EQUITABLE RETIREE HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01MICHAEL FRANCESCONI2023-10-09 SHEILA LABITA2023-10-09
5022021-01-01SHEILA LABITA2022-10-17 BARBARA LENKIEWICZ2022-10-17
5022020-01-01SHEILA LABITA2021-10-15 BARBARA LENKIEWICZ2021-10-15
5022019-01-01SHEILA LABITA2020-10-12 BARBARA LENKIEWICZ2020-10-12
5022018-01-01SHEILA LABITA2019-10-15 BARBARA LENKIEWICZ2019-10-15
5022017-01-01
5022016-01-01SHEILA LABITA BARBARA LENKIEWICZ2017-10-16
5022015-01-01SHEILA LABITA BARBARA LENKIEWICZ2016-10-17
5022015-01-01SHEILA LABITA BARBARA LENKIEWICZ2016-10-20

Plan Statistics for EQUITABLE RETIREE HEALTH PLAN

401k plan membership statisitcs for EQUITABLE RETIREE HEALTH PLAN

Measure Date Value
2022: EQUITABLE RETIREE HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-013,282
Total number of active participants reported on line 7a of the Form 55002022-01-010
Number of retired or separated participants receiving benefits2022-01-013,108
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-013,108
2021: EQUITABLE RETIREE HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-013,373
Total number of active participants reported on line 7a of the Form 55002021-01-0110
Number of retired or separated participants receiving benefits2021-01-013,282
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-013,292
2020: EQUITABLE RETIREE HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-016,938
Total number of active participants reported on line 7a of the Form 55002020-01-0155
Number of retired or separated participants receiving benefits2020-01-013,462
Number of other retired or separated participants entitled to future benefits2020-01-012,972
Total of all active and inactive participants2020-01-016,489
2019: EQUITABLE RETIREE HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-017,346
Total number of active participants reported on line 7a of the Form 55002019-01-0151
Number of retired or separated participants receiving benefits2019-01-013,791
Number of other retired or separated participants entitled to future benefits2019-01-012,842
Total of all active and inactive participants2019-01-016,684
2018: EQUITABLE RETIREE HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-017,214
Total number of active participants reported on line 7a of the Form 55002018-01-0159
Number of retired or separated participants receiving benefits2018-01-014,060
Number of other retired or separated participants entitled to future benefits2018-01-012,696
Total of all active and inactive participants2018-01-016,815
2017: EQUITABLE RETIREE HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-017,682
Total number of active participants reported on line 7a of the Form 55002017-01-0169
Number of retired or separated participants receiving benefits2017-01-014,337
Number of other retired or separated participants entitled to future benefits2017-01-012,584
Total of all active and inactive participants2017-01-016,990
2016: EQUITABLE RETIREE HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-017,314
Total number of active participants reported on line 7a of the Form 55002016-01-0178
Number of retired or separated participants receiving benefits2016-01-014,556
Number of other retired or separated participants entitled to future benefits2016-01-012,450
Total of all active and inactive participants2016-01-017,084
2015: EQUITABLE RETIREE HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-017,990
Total number of active participants reported on line 7a of the Form 55002015-01-01101
Number of retired or separated participants receiving benefits2015-01-015,056
Number of other retired or separated participants entitled to future benefits2015-01-012,331
Total of all active and inactive participants2015-01-017,488

Financial Data on EQUITABLE RETIREE HEALTH PLAN

Measure Date Value
2021 : EQUITABLE RETIREE HEALTH PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets2021-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$319,432
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2021-12-31$4,285,912
Total income from all sources (including contributions)2021-12-31$3,526,024
Total loss/gain on sale of assets2021-12-31$-3
Total of all expenses incurred2021-12-31$6,670,531
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2021-12-31$6,141,048
Total contributions o plan (from employers,participants, others, non cash contrinutions)2021-12-31$3,525,800
Value of total assets at end of year2021-12-31$167,835
Value of total assets at beginning of year2021-12-31$7,278,822
Total of administrative expenses incurred including professional, contract, advisory and management fees2021-12-31$529,483
Total interest from all sources2021-12-31$225
Total dividends received (eg from common stock, registered investment company shares)2021-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-12-31No
Administrative expenses professional fees incurred2021-12-31$529,483
Was this plan covered by a fidelity bond2021-12-31Yes
Value of fidelity bond cover2021-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2021-12-31No
Contributions received from participants2021-12-31$2,289,643
Participant contributions at end of year2021-12-31$167,835
Participant contributions at beginning of year2021-12-31$2,336,838
Value of other receiveables (less allowance for doubtful accounts) at end of year2021-12-31$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2021-12-31$3,343,819
Other income not declared elsewhere2021-12-31$2
Liabilities. Value of operating payables at end of year2021-12-31$96,128
Liabilities. Value of operating payables at beginning of year2021-12-31$218,526
Total non interest bearing cash at end of year2021-12-31$0
Total non interest bearing cash at beginning of year2021-12-31$644,239
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Value of net income/loss2021-12-31$-3,144,507
Value of net assets at end of year (total assets less liabilities)2021-12-31$-151,597
Value of net assets at beginning of year (total assets less liabilities)2021-12-31$2,992,910
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2021-12-31No
Were any leases to which the plan was party in default or uncollectible2021-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2021-12-31$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2021-12-31$953,926
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2021-12-31$225
Expenses. Payments to insurance carriers foe the provision of benefits2021-12-31$3,400,379
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-12-31Yes
Was there a failure to transmit to the plan any participant contributions2021-12-31No
Has the plan failed to provide any benefit when due under the plan2021-12-31No
Contributions received in cash from employer2021-12-31$1,236,157
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2021-12-31$2,740,669
Liabilities. Value of benefit claims payable at end of year2021-12-31$223,304
Liabilities. Value of benefit claims payable at beginning of year2021-12-31$4,067,386
Did the plan have assets held for investment2021-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-12-31No
Aggregate proceeds on sale of assets2021-12-31$-3
Opinion of an independent qualified public accountant for this plan2021-12-31Unqualified
Accountancy firm name2021-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2021-12-31134008324
2020 : EQUITABLE RETIREE HEALTH PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets2020-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$4,285,912
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2020-12-31$9,615,491
Total income from all sources (including contributions)2020-12-31$25,591,164
Total loss/gain on sale of assets2020-12-31$-2,170
Total of all expenses incurred2020-12-31$23,940,517
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2020-12-31$21,166,118
Total contributions o plan (from employers,participants, others, non cash contrinutions)2020-12-31$25,526,637
Value of total assets at end of year2020-12-31$7,278,822
Value of total assets at beginning of year2020-12-31$10,957,754
Total of administrative expenses incurred including professional, contract, advisory and management fees2020-12-31$2,774,399
Total interest from all sources2020-12-31$44,299
Total dividends received (eg from common stock, registered investment company shares)2020-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-12-31No
Administrative expenses professional fees incurred2020-12-31$2,774,399
Was this plan covered by a fidelity bond2020-12-31Yes
Value of fidelity bond cover2020-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2020-12-31No
Contributions received from participants2020-12-31$16,825,488
Participant contributions at end of year2020-12-31$2,336,838
Participant contributions at beginning of year2020-12-31$1,361,548
Value of other receiveables (less allowance for doubtful accounts) at end of year2020-12-31$3,343,819
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2020-12-31$2,737,651
Other income not declared elsewhere2020-12-31$22,398
Liabilities. Value of operating payables at end of year2020-12-31$218,526
Liabilities. Value of operating payables at beginning of year2020-12-31$185,353
Total non interest bearing cash at end of year2020-12-31$644,239
Total non interest bearing cash at beginning of year2020-12-31$641,427
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Value of net income/loss2020-12-31$1,650,647
Value of net assets at end of year (total assets less liabilities)2020-12-31$2,992,910
Value of net assets at beginning of year (total assets less liabilities)2020-12-31$1,342,263
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2020-12-31No
Were any leases to which the plan was party in default or uncollectible2020-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2020-12-31$953,926
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2020-12-31$6,217,128
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2020-12-31$44,299
Expenses. Payments to insurance carriers foe the provision of benefits2020-12-31$155,518
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-12-31Yes
Was there a failure to transmit to the plan any participant contributions2020-12-31No
Has the plan failed to provide any benefit when due under the plan2020-12-31No
Contributions received in cash from employer2020-12-31$8,701,149
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2020-12-31$21,010,600
Liabilities. Value of benefit claims payable at end of year2020-12-31$4,067,386
Liabilities. Value of benefit claims payable at beginning of year2020-12-31$9,430,138
Did the plan have assets held for investment2020-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-12-31No
Aggregate proceeds on sale of assets2020-12-31$-2,170
Opinion of an independent qualified public accountant for this plan2020-12-31Unqualified
Accountancy firm name2020-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2020-12-31134008324
2019 : EQUITABLE RETIREE HEALTH PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets2019-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$9,615,491
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2019-12-31$6,161,173
Total income from all sources (including contributions)2019-12-31$34,312,304
Total loss/gain on sale of assets2019-12-31$-413
Total of all expenses incurred2019-12-31$36,225,957
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2019-12-31$33,879,970
Total contributions o plan (from employers,participants, others, non cash contrinutions)2019-12-31$34,043,772
Value of total assets at end of year2019-12-31$10,957,754
Value of total assets at beginning of year2019-12-31$9,417,089
Total of administrative expenses incurred including professional, contract, advisory and management fees2019-12-31$2,345,987
Total interest from all sources2019-12-31$141,288
Total dividends received (eg from common stock, registered investment company shares)2019-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-12-31No
Administrative expenses professional fees incurred2019-12-31$2,345,987
Was this plan covered by a fidelity bond2019-12-31Yes
Value of fidelity bond cover2019-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2019-12-31No
Contributions received from participants2019-12-31$18,032,425
Participant contributions at end of year2019-12-31$1,361,548
Participant contributions at beginning of year2019-12-31$1,291,048
Value of other receiveables (less allowance for doubtful accounts) at end of year2019-12-31$2,737,651
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2019-12-31$4,697,018
Other income not declared elsewhere2019-12-31$127,657
Liabilities. Value of operating payables at end of year2019-12-31$185,353
Liabilities. Value of operating payables at beginning of year2019-12-31$76,328
Total non interest bearing cash at end of year2019-12-31$641,427
Total non interest bearing cash at beginning of year2019-12-31$626,979
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Value of net income/loss2019-12-31$-1,913,653
Value of net assets at end of year (total assets less liabilities)2019-12-31$1,342,263
Value of net assets at beginning of year (total assets less liabilities)2019-12-31$3,255,916
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2019-12-31No
Were any leases to which the plan was party in default or uncollectible2019-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2019-12-31$6,217,128
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2019-12-31$123,137
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2019-12-31$141,288
Expenses. Payments to insurance carriers foe the provision of benefits2019-12-31$186,492
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-12-31Yes
Was there a failure to transmit to the plan any participant contributions2019-12-31No
Has the plan failed to provide any benefit when due under the plan2019-12-31No
Contributions received in cash from employer2019-12-31$16,011,347
Employer contributions (assets) at end of year2019-12-31$0
Employer contributions (assets) at beginning of year2019-12-31$2,678,907
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2019-12-31$33,693,478
Liabilities. Value of benefit claims payable at end of year2019-12-31$9,430,138
Liabilities. Value of benefit claims payable at beginning of year2019-12-31$6,084,845
Did the plan have assets held for investment2019-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-12-31No
Aggregate proceeds on sale of assets2019-12-31$-413
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2019-12-31No
Opinion of an independent qualified public accountant for this plan2019-12-31Unqualified
Accountancy firm name2019-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2019-12-31134008324
2018 : EQUITABLE RETIREE HEALTH PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets2018-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$6,161,173
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2018-12-31$3,467,056
Total income from all sources (including contributions)2018-12-31$39,362,135
Total loss/gain on sale of assets2018-12-31$-128
Total of all expenses incurred2018-12-31$35,758,508
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2018-12-31$33,543,205
Total contributions o plan (from employers,participants, others, non cash contrinutions)2018-12-31$39,270,028
Value of total assets at end of year2018-12-31$9,417,089
Value of total assets at beginning of year2018-12-31$3,119,345
Total of administrative expenses incurred including professional, contract, advisory and management fees2018-12-31$2,215,303
Total interest from all sources2018-12-31$59,344
Total dividends received (eg from common stock, registered investment company shares)2018-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Administrative expenses professional fees incurred2018-12-31$2,215,303
Was this plan covered by a fidelity bond2018-12-31Yes
Value of fidelity bond cover2018-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Contributions received from participants2018-12-31$15,773,238
Participant contributions at end of year2018-12-31$1,291,048
Participant contributions at beginning of year2018-12-31$1,211,739
Value of other receiveables (less allowance for doubtful accounts) at end of year2018-12-31$4,697,018
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2018-12-31$1,076,672
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2018-12-31$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2018-12-31$3,940
Other income not declared elsewhere2018-12-31$32,891
Liabilities. Value of operating payables at end of year2018-12-31$76,328
Liabilities. Value of operating payables at beginning of year2018-12-31$249,260
Total non interest bearing cash at end of year2018-12-31$626,979
Total non interest bearing cash at beginning of year2018-12-31$586,406
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net income/loss2018-12-31$3,603,627
Value of net assets at end of year (total assets less liabilities)2018-12-31$3,255,916
Value of net assets at beginning of year (total assets less liabilities)2018-12-31$-347,711
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2018-12-31$123,137
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2018-12-31$244,528
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2018-12-31$59,344
Expenses. Payments to insurance carriers foe the provision of benefits2018-12-31$194,021
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31Yes
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Contributions received in cash from employer2018-12-31$23,496,790
Employer contributions (assets) at end of year2018-12-31$2,678,907
Employer contributions (assets) at beginning of year2018-12-31$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2018-12-31$33,349,184
Liabilities. Value of benefit claims payable at end of year2018-12-31$6,084,845
Liabilities. Value of benefit claims payable at beginning of year2018-12-31$3,213,856
Did the plan have assets held for investment2018-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
Aggregate proceeds on sale of assets2018-12-31$-128
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2018-12-31No
Opinion of an independent qualified public accountant for this plan2018-12-31Unqualified
Accountancy firm name2018-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2018-12-31134008324
2017 : EQUITABLE RETIREE HEALTH PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets2017-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$3,467,056
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2017-12-31$3,754,795
Total income from all sources (including contributions)2017-12-31$33,340,644
Total loss/gain on sale of assets2017-12-31$-503
Total of all expenses incurred2017-12-31$33,822,562
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2017-12-31$31,233,025
Total contributions o plan (from employers,participants, others, non cash contrinutions)2017-12-31$33,284,921
Value of total assets at end of year2017-12-31$3,119,345
Value of total assets at beginning of year2017-12-31$3,889,002
Total of administrative expenses incurred including professional, contract, advisory and management fees2017-12-31$2,589,537
Total interest from all sources2017-12-31$35,628
Total dividends received (eg from common stock, registered investment company shares)2017-12-31$0
Administrative expenses professional fees incurred2017-12-31$611,257
Was this plan covered by a fidelity bond2017-12-31Yes
Value of fidelity bond cover2017-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Contributions received from participants2017-12-31$14,831,866
Participant contributions at end of year2017-12-31$1,211,739
Participant contributions at beginning of year2017-12-31$1,444,569
Value of other receiveables (less allowance for doubtful accounts) at end of year2017-12-31$1,076,672
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2017-12-31$1,718,272
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2017-12-31$3,940
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2017-12-31$3,940
Other income not declared elsewhere2017-12-31$20,598
Administrative expenses (other) incurred2017-12-31$138,915
Liabilities. Value of operating payables at end of year2017-12-31$249,260
Liabilities. Value of operating payables at beginning of year2017-12-31$257,864
Total non interest bearing cash at end of year2017-12-31$586,406
Total non interest bearing cash at beginning of year2017-12-31$592,718
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net income/loss2017-12-31$-481,918
Value of net assets at end of year (total assets less liabilities)2017-12-31$-347,711
Value of net assets at beginning of year (total assets less liabilities)2017-12-31$134,207
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Investment advisory and management fees2017-12-31$14,377
Value of interest in registered invesment companies (eg mutual funds) at end of year2017-12-31$244,528
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2017-12-31$133,443
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2017-12-31$35,628
Expenses. Payments to insurance carriers foe the provision of benefits2017-12-31$186,147
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31Yes
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Contributions received in cash from employer2017-12-31$18,453,055
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2017-12-31$31,046,878
Contract administrator fees2017-12-31$1,824,988
Liabilities. Value of benefit claims payable at end of year2017-12-31$3,213,856
Liabilities. Value of benefit claims payable at beginning of year2017-12-31$3,492,991
Did the plan have assets held for investment2017-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
Aggregate proceeds on sale of assets2017-12-31$-503
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2017-12-31No
Opinion of an independent qualified public accountant for this plan2017-12-31Unqualified
Accountancy firm name2017-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2017-12-31134008324
2016 : EQUITABLE RETIREE HEALTH PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets2016-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$3,754,795
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2016-12-31$4,515,593
Total income from all sources (including contributions)2016-12-31$36,058,445
Total loss/gain on sale of assets2016-12-31$2,141
Total of all expenses incurred2016-12-31$35,860,255
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2016-12-31$33,175,508
Total contributions o plan (from employers,participants, others, non cash contrinutions)2016-12-31$36,019,627
Value of total assets at end of year2016-12-31$3,889,002
Value of total assets at beginning of year2016-12-31$4,451,610
Total of administrative expenses incurred including professional, contract, advisory and management fees2016-12-31$2,684,747
Total interest from all sources2016-12-31$17,101
Total dividends received (eg from common stock, registered investment company shares)2016-12-31$0
Administrative expenses professional fees incurred2016-12-31$2,684,747
Was this plan covered by a fidelity bond2016-12-31Yes
Value of fidelity bond cover2016-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2016-12-31No
Contributions received from participants2016-12-31$17,968,162
Participant contributions at end of year2016-12-31$1,444,569
Participant contributions at beginning of year2016-12-31$1,365,860
Value of other receiveables (less allowance for doubtful accounts) at end of year2016-12-31$1,718,272
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2016-12-31$1,285,967
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2016-12-31$3,940
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2016-12-31$3,940
Other income not declared elsewhere2016-12-31$19,576
Liabilities. Value of operating payables at end of year2016-12-31$257,864
Liabilities. Value of operating payables at beginning of year2016-12-31$292,113
Total non interest bearing cash at end of year2016-12-31$592,718
Total non interest bearing cash at beginning of year2016-12-31$475,027
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Value of net income/loss2016-12-31$198,190
Value of net assets at end of year (total assets less liabilities)2016-12-31$134,207
Value of net assets at beginning of year (total assets less liabilities)2016-12-31$-63,983
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-12-31No
Were any leases to which the plan was party in default or uncollectible2016-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2016-12-31$133,443
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2016-12-31$1,324,756
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2016-12-31$17,101
Expenses. Payments to insurance carriers foe the provision of benefits2016-12-31$196,954
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-12-31Yes
Was there a failure to transmit to the plan any participant contributions2016-12-31No
Has the plan failed to provide any benefit when due under the plan2016-12-31No
Contributions received in cash from employer2016-12-31$18,051,465
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2016-12-31$32,978,554
Liabilities. Value of benefit claims payable at end of year2016-12-31$3,492,991
Liabilities. Value of benefit claims payable at beginning of year2016-12-31$4,219,540
Did the plan have assets held for investment2016-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-12-31No
Aggregate proceeds on sale of assets2016-12-31$2,141
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2016-12-31No
Opinion of an independent qualified public accountant for this plan2016-12-31Unqualified
Accountancy firm name2016-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2016-12-31134008324
2015 : EQUITABLE RETIREE HEALTH PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets2015-12-31$0
Total transfer of assets to this plan2015-12-31$6,954,052
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$2,155,157
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$0
Total income from all sources (including contributions)2015-12-31$37,596,364
Total loss/gain on sale of assets2015-12-31$0
Total of all expenses incurred2015-12-31$42,253,963
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2015-12-31$39,747,485
Total contributions o plan (from employers,participants, others, non cash contrinutions)2015-12-31$37,590,466
Value of total assets at end of year2015-12-31$4,451,610
Value of total assets at beginning of year2015-12-31$0
Total of administrative expenses incurred including professional, contract, advisory and management fees2015-12-31$2,506,478
Total interest from all sources2015-12-31$5,898
Total dividends received (eg from common stock, registered investment company shares)2015-12-31$0
Administrative expenses professional fees incurred2015-12-31$2,506,478
Was this plan covered by a fidelity bond2015-12-31Yes
Value of fidelity bond cover2015-12-31$25,000,000
Were there any nonexempt tranactions with any party-in-interest2015-12-31No
Contributions received from participants2015-12-31$17,029,741
Participant contributions at end of year2015-12-31$1,365,860
Participant contributions at beginning of year2015-12-31$0
Value of other receiveables (less allowance for doubtful accounts) at end of year2015-12-31$1,285,967
Value of other receiveables (less allowance for doubtful accounts) at beginning of year2015-12-31$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year2015-12-31$3,940
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year2015-12-31$0
Liabilities. Value of operating payables at end of year2015-12-31$375,679
Liabilities. Value of operating payables at beginning of year2015-12-31$0
Total non interest bearing cash at end of year2015-12-31$475,027
Total non interest bearing cash at beginning of year2015-12-31$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Value of net income/loss2015-12-31$-4,657,599
Value of net assets at end of year (total assets less liabilities)2015-12-31$2,296,453
Value of net assets at beginning of year (total assets less liabilities)2015-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Were any leases to which the plan was party in default or uncollectible2015-12-31No
Value of interest in registered invesment companies (eg mutual funds) at end of year2015-12-31$1,324,756
Value of interest in registered invesment companies (eg mutual funds) at beginning of year2015-12-31$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)2015-12-31$5,898
Expenses. Payments to insurance carriers foe the provision of benefits2015-12-31$202,298
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-12-31Yes
Was there a failure to transmit to the plan any participant contributions2015-12-31No
Has the plan failed to provide any benefit when due under the plan2015-12-31No
Contributions received in cash from employer2015-12-31$20,560,725
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers2015-12-31$39,545,187
Liabilities. Value of benefit claims payable at end of year2015-12-31$1,775,538
Liabilities. Value of benefit claims payable at beginning of year2015-12-31$0
Did the plan have assets held for investment2015-12-31Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-12-31No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)2015-12-31Yes
Opinion of an independent qualified public accountant for this plan2015-12-31Disclaimer
Accountancy firm name2015-12-31PRICEWATERHOUSECOOPERS, LLP
Accountancy firm EIN2015-12-31134008324

Form 5500 Responses for EQUITABLE RETIREE HEALTH PLAN

2022: EQUITABLE RETIREE HEALTH PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: EQUITABLE RETIREE HEALTH PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – TrustYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement - TrustYes
2020: EQUITABLE RETIREE HEALTH PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – TrustYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement - TrustYes
2019: EQUITABLE RETIREE HEALTH PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – TrustYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement - TrustYes
2018: EQUITABLE RETIREE HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – TrustYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement - TrustYes
2017: EQUITABLE RETIREE HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – TrustYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement - TrustYes
2016: EQUITABLE RETIREE HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – TrustYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement - TrustYes
2015: EQUITABLE RETIREE HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01First time form 5500 has been submittedYes
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – TrustYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number231691
Policy instance 23
Insurance contract or identification number231691
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $168
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $11,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $168
Insurance broker organization code?3
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number*SEE BELOW
Policy instance 10
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered2
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $185
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $185
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number*SEE BELOW
Policy instance 9
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered2
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $498
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $34,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $498
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755624
Policy instance 8
Insurance contract or identification number755624
Number of Individuals Covered114
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,950
Total amount of fees paid to insurance companyUSD $6,256
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,582,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,950
Amount paid for insurance broker fees6256
Additional information about fees paid to insurance brokerSERVICE FREE AGREEMENT
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0154460
Policy instance 7
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $33
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number0154460
Policy instance 6
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $12
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number0154460
Policy instance 5
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $16
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0154460
Policy instance 4
Insurance contract or identification number0154460
Number of Individuals Covered2
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $119
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $119
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3339125*
Policy instance 3
Insurance contract or identification number3339125*
Number of Individuals Covered8
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $532
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $26,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees532
Additional information about fees paid to insurance brokerBENEFIT ADVISOR PAYMENTS
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0866425*
Policy instance 2
Insurance contract or identification number0866425*
Number of Individuals Covered33
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,971
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $437,470
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,971
Insurance broker organization code?3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 1
Insurance contract or identification numberSP0003450
Number of Individuals Covered20
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $3,009
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT, SUPP
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,009
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
Policy contract number30042693
Policy instance 11
Insurance contract or identification number30042693
Number of Individuals Covered83
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $623
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $623
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number35601
Policy instance 12
Insurance contract or identification number35601
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $9
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number22594
Policy instance 22
Insurance contract or identification number22594
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $36
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,822
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number*SEE BELOW
Policy instance 21
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $71
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number2499862
Policy instance 20
Insurance contract or identification number2499862
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $200
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedPREPAID DENTAL
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 CarrierUSD $6,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $200
Insurance broker organization code?3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number76837
Policy instance 19
Insurance contract or identification number76837
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30
Insurance broker organization code?3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number16488
Policy instance 18
Insurance contract or identification number16488
Number of Individuals Covered114
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $3,467
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,467
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99213131001
Policy instance 17
Insurance contract or identification number99213131001
Number of Individuals Covered2
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99213051001
Policy instance 16
Insurance contract or identification number99213051001
Number of Individuals Covered20
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $52
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99212971001
Policy instance 15
Insurance contract or identification number99212971001
Number of Individuals Covered24
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $58
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58
Insurance broker organization code?3
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number8104400
Policy instance 14
Insurance contract or identification number8104400
Number of Individuals Covered1
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $92
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $4,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $92
Insurance broker organization code?3
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number270119
Policy instance 13
Insurance contract or identification number270119
Number of Individuals Covered10
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,253
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $215,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,253
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99213051001
Policy instance 18
Insurance contract or identification number99213051001
Number of Individuals Covered12
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $52
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99213131001
Policy instance 19
Insurance contract or identification number99213131001
Number of Individuals Covered3
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13
Insurance broker organization code?3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number16488
Policy instance 20
Insurance contract or identification number16488
Number of Individuals Covered248
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,325
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $144,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,325
Insurance broker organization code?3
DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 )
Policy contract number76837
Policy instance 21
Insurance contract or identification number76837
Number of Individuals Covered5
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $34
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number2499862
Policy instance 22
Insurance contract or identification number2499862
Number of Individuals Covered6
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $71
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedPREPAID DENTAL
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 CarrierUSD $6,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71
Insurance broker organization code?3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number793246
Policy instance 23
Insurance contract or identification number793246
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $30
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25
Insurance broker organization code?3
UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 )
Policy contract number*SEE BELOW
Policy instance 24
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $54
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54
Insurance broker organization code?3
FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )
Policy contract number99212971001
Policy instance 17
Insurance contract or identification number99212971001
Number of Individuals Covered3
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $73
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73
Insurance broker organization code?3
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number8104400
Policy instance 16
Insurance contract or identification number8104400
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $134
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $134
Insurance broker organization code?3
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086*
Policy instance 1
Insurance contract or identification number20086*
Number of Individuals Covered127
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $57,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 2
Insurance contract or identification numberSP0003450
Number of Individuals Covered16
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,698
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT
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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,698
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0866425*
Policy instance 3
Insurance contract or identification number0866425*
Number of Individuals Covered58
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $8,361
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $424,117
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,361
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3339125*
Policy instance 4
Insurance contract or identification number3339125*
Number of Individuals Covered2
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,472
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $98,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1472
Additional information about fees paid to insurance brokerBENEFIT ADVISOR PAYMENTS BROKER AND GENERAL AGENTS COMBINED
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0154460
Policy instance 5
Insurance contract or identification number0154460
Number of Individuals Covered2
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $67
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $67
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC., A FLORIDA CORPORATION (National Association of Insurance Commissioners NAIC id number: 52009 )
Policy contract number0154460
Policy instance 6
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $28
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 )
Policy contract number0154460
Policy instance 7
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $7
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number0154460
Policy instance 8
Insurance contract or identification number0154460
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number755624
Policy instance 9
Insurance contract or identification number755624
Number of Individuals Covered160
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $40,314
Total amount of fees paid to insurance companyUSD $2,478
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,111,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,314
Amount paid for insurance broker fees2478
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )
Policy contract number*SEE BELOW
Policy instance 10
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $554
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $43,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $554
Insurance broker organization code?3
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number*SEE BELOW
Policy instance 11
Insurance contract or identification number*SEE BELOW
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $269
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $9,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $269
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )
Policy contract number30042693
Policy instance 12
Insurance contract or identification number30042693
Number of Individuals Covered86
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $770
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $15,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $770
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 )
Policy contract number35601
Policy instance 13
Insurance contract or identification number35601
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $64
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $5,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $64
Insurance broker organization code?3
EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 )
Policy contract number270119
Policy instance 14
Insurance contract or identification number270119
Number of Individuals Covered15
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,712
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $345,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,712
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number604163
Policy instance 15
Insurance contract or identification number604163
Number of Individuals Covered1
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $221
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $12,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $221
Insurance broker organization code?3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 3
Insurance contract or identification numberSP0003450
Number of Individuals Covered9
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,982
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,982
Insurance broker organization code?3
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086*
Policy instance 1
Insurance contract or identification number20086*
Number of Individuals Covered7423
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $80,675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number12583 1
Policy instance 2
Insurance contract or identification number12583 1
Number of Individuals Covered0
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $10,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086*
Policy instance 1
Insurance contract or identification number20086*
Number of Individuals Covered7541
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $86,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number12583 1
Policy instance 2
Insurance contract or identification number12583 1
Number of Individuals Covered4
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $30,739
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 3
Insurance contract or identification numberSP0003450
Number of Individuals Covered18
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $17,699
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,699
Insurance broker organization code?3
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086*
Policy instance 1
Insurance contract or identification number20086*
Number of Individuals Covered7625
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $93,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 3
Insurance contract or identification numberSP0003450
Number of Individuals Covered19
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $17,941
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,941
Insurance broker organization code?3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number12583 1
Policy instance 2
Insurance contract or identification number12583 1
Number of Individuals Covered4
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $30,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 3
Insurance contract or identification numberSP0003450
Number of Individuals Covered31
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $22,690
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedMAJOR MEDICAL, TELECONSULTA, ORGAN AND TISSUE TRANSPLANT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,690
Insurance broker organization code?3
Insurance broker nameAON RISK SERVICES OF PR
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number12583 1
Policy instance 2
Insurance contract or identification number12583 1
Number of Individuals Covered3
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $22,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086*
Policy instance 1
Insurance contract or identification number20086*
Number of Individuals Covered7704
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $99,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number20086
Policy instance 1
Insurance contract or identification number20086
Number of Individuals Covered7799
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $111,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0003450
Policy instance 3
Insurance contract or identification numberSP0003450
Number of Individuals Covered14
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,676
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,676
Insurance broker organization code?3
Insurance broker nameHEWITT INSURANCE, INC
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number12583
Policy instance 2
Insurance contract or identification number12583
Number of Individuals Covered4
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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