PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	501

PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

PARADIGM ACQUISITION CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:	PARADIGM ACQUISITION CORPORATION
Employer identification number (EIN):	141948706
NAIC Classification:	524290

Additional information about PARADIGM ACQUISITION CORPORATION

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C2852217

More information about PARADIGM ACQUISITION CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KAREN JONES	2023-07-06
501	2021-05-01	KAREN JONES	2022-07-15
501	2020-05-01	KAREN JONES	2021-09-16
501	2019-05-01	KAREN JONES	2020-10-02
501	2018-05-01	KAREN JONES	2019-11-20
501	2017-05-01
501	2016-05-01
501	2015-05-01	TOM MASTRI
501	2014-05-01	ERIN HARTZELL
501	2013-05-01	ERIN HARTZELL
501	2012-05-01	ERIN KRAJEWSKI
501	2011-05-01	ERIN KRAJEWSKI
501	2010-05-01	ERIN KRAJEWSKI
501	2009-05-01	ERIN KRAJEWSKI
501	2009-05-01

Plan Statistics for PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN

Measure	Date	Value
2022: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,100
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	1,253
Number of retired or separated participants receiving benefits	2022-01-01	9
Number of other retired or separated participants entitled to future benefits	2022-01-01	57
Total of all active and inactive participants	2022-01-01	1,319
Number of employers contributing to the scheme	2022-01-01	0
2021: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-05-01	1,023
Total number of active participants reported on line 7a of the Form 5500	2021-05-01	1,093
Number of retired or separated participants receiving benefits	2021-05-01	5
Number of other retired or separated participants entitled to future benefits	2021-05-01	28
Total of all active and inactive participants	2021-05-01	1,126
Number of employers contributing to the scheme	2021-05-01	0
2020: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-05-01	1,083
Total number of active participants reported on line 7a of the Form 5500	2020-05-01	974
Number of retired or separated participants receiving benefits	2020-05-01	13
Number of other retired or separated participants entitled to future benefits	2020-05-01	36
Total of all active and inactive participants	2020-05-01	1,023
Number of employers contributing to the scheme	2020-05-01	0
2019: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-05-01	213
Total number of active participants reported on line 7a of the Form 5500	2019-05-01	1,021
Number of retired or separated participants receiving benefits	2019-05-01	0
Number of other retired or separated participants entitled to future benefits	2019-05-01	0
Total of all active and inactive participants	2019-05-01	1,021
Number of employers contributing to the scheme	2019-05-01	0
2018: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-05-01	207
Total number of active participants reported on line 7a of the Form 5500	2018-05-01	213
Number of retired or separated participants receiving benefits	2018-05-01	0
Number of other retired or separated participants entitled to future benefits	2018-05-01	0
Total of all active and inactive participants	2018-05-01	213
Number of employers contributing to the scheme	2018-05-01	0
2017: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-05-01	201
Total number of active participants reported on line 7a of the Form 5500	2017-05-01	207
Number of retired or separated participants receiving benefits	2017-05-01	0
Number of other retired or separated participants entitled to future benefits	2017-05-01	0
Total of all active and inactive participants	2017-05-01	207
2016: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-05-01	194
Total number of active participants reported on line 7a of the Form 5500	2016-05-01	204
Number of retired or separated participants receiving benefits	2016-05-01	0
Number of other retired or separated participants entitled to future benefits	2016-05-01	0
Total of all active and inactive participants	2016-05-01	204
2015: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-05-01	195
Total number of active participants reported on line 7a of the Form 5500	2015-05-01	195
Number of retired or separated participants receiving benefits	2015-05-01	0
Number of other retired or separated participants entitled to future benefits	2015-05-01	0
Total of all active and inactive participants	2015-05-01	195
2014: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-05-01	198
Total number of active participants reported on line 7a of the Form 5500	2014-05-01	198
Number of retired or separated participants receiving benefits	2014-05-01	0
Number of other retired or separated participants entitled to future benefits	2014-05-01	0
Total of all active and inactive participants	2014-05-01	198
2013: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-05-01	166
Total number of active participants reported on line 7a of the Form 5500	2013-05-01	166
Number of retired or separated participants receiving benefits	2013-05-01	0
Number of other retired or separated participants entitled to future benefits	2013-05-01	0
Total of all active and inactive participants	2013-05-01	166
2012: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-05-01	171
Total number of active participants reported on line 7a of the Form 5500	2012-05-01	162
Number of retired or separated participants receiving benefits	2012-05-01	3
Number of other retired or separated participants entitled to future benefits	2012-05-01	0
Total of all active and inactive participants	2012-05-01	165
2011: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-05-01	161
Total number of active participants reported on line 7a of the Form 5500	2011-05-01	171
Number of retired or separated participants receiving benefits	2011-05-01	0
Number of other retired or separated participants entitled to future benefits	2011-05-01	0
Total of all active and inactive participants	2011-05-01	171
2010: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-05-01	136
Total number of active participants reported on line 7a of the Form 5500	2010-05-01	159
Number of retired or separated participants receiving benefits	2010-05-01	2
Number of other retired or separated participants entitled to future benefits	2010-05-01	0
Total of all active and inactive participants	2010-05-01	161
2009: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-05-01	133
Total number of active participants reported on line 7a of the Form 5500	2009-05-01	133
Number of retired or separated participants receiving benefits	2009-05-01	4
Number of other retired or separated participants entitled to future benefits	2009-05-01	0
Total of all active and inactive participants	2009-05-01	137

Form 5500 Responses for PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN

2022: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-05-01	Type of plan entity	Single employer plan
2021-05-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-05-01	Plan funding arrangement – Insurance	Yes
2021-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-05-01	Plan benefit arrangement – Insurance	Yes
2021-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-05-01	Type of plan entity	Single employer plan
2020-05-01	Plan funding arrangement – Insurance	Yes
2020-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-05-01	Plan benefit arrangement – Insurance	Yes
2020-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-05-01	Type of plan entity	Single employer plan
2019-05-01	Plan funding arrangement – Insurance	Yes
2019-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-05-01	Plan benefit arrangement – Insurance	Yes
2019-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-05-01	Type of plan entity	Single employer plan
2018-05-01	Plan funding arrangement – Insurance	Yes
2018-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-05-01	Plan benefit arrangement – Insurance	Yes
2018-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-05-01	Type of plan entity	Single employer plan
2017-05-01	Plan funding arrangement – Insurance	Yes
2017-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-05-01	Plan benefit arrangement – Insurance	Yes
2017-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-05-01	Type of plan entity	Single employer plan
2016-05-01	Submission has been amended	No
2016-05-01	This submission is the final filing	No
2016-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-05-01	Plan is a collectively bargained plan	No
2016-05-01	Plan funding arrangement – Insurance	Yes
2016-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-05-01	Plan benefit arrangement – Insurance	Yes
2016-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-05-01	Type of plan entity	Single employer plan
2015-05-01	Submission has been amended	No
2015-05-01	This submission is the final filing	No
2015-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-05-01	Plan is a collectively bargained plan	No
2015-05-01	Plan funding arrangement – Insurance	Yes
2015-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-05-01	Plan benefit arrangement – Insurance	Yes
2015-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-05-01	Type of plan entity	Single employer plan
2014-05-01	Submission has been amended	No
2014-05-01	This submission is the final filing	No
2014-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-05-01	Plan is a collectively bargained plan	No
2014-05-01	Plan funding arrangement – Insurance	Yes
2014-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-05-01	Plan benefit arrangement – Insurance	Yes
2014-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-05-01	Type of plan entity	Single employer plan
2013-05-01	Submission has been amended	No
2013-05-01	This submission is the final filing	No
2013-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-05-01	Plan is a collectively bargained plan	No
2013-05-01	Plan funding arrangement – Insurance	Yes
2013-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-05-01	Plan benefit arrangement – Insurance	Yes
2013-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-05-01	Type of plan entity	Single employer plan
2012-05-01	Submission has been amended	Yes
2012-05-01	This submission is the final filing	No
2012-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-05-01	Plan is a collectively bargained plan	No
2012-05-01	Plan funding arrangement – Insurance	Yes
2012-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-05-01	Plan benefit arrangement – Insurance	Yes
2012-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-05-01	Type of plan entity	Single employer plan
2011-05-01	Submission has been amended	Yes
2011-05-01	This submission is the final filing	No
2011-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-05-01	Plan is a collectively bargained plan	No
2011-05-01	Plan funding arrangement – Insurance	Yes
2011-05-01	Plan benefit arrangement – Insurance	Yes
2010: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-05-01	Type of plan entity	Single employer plan
2010-05-01	Submission has been amended	Yes
2010-05-01	This submission is the final filing	No
2010-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-05-01	Plan is a collectively bargained plan	No
2010-05-01	Plan funding arrangement – Insurance	Yes
2010-05-01	Plan benefit arrangement – Insurance	Yes
2009: PARADIGM ACQUISITION CORPORATION COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-05-01	Type of plan entity	Single employer plan
2009-05-01	Submission has been amended	Yes
2009-05-01	This submission is the final filing	No
2009-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-05-01	Plan is a collectively bargained plan	No
2009-05-01	Plan funding arrangement – Insurance	Yes
2009-05-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	15274832
Policy instance	3
Insurance contract or identification number 15274832 Number of Individuals Covered 1301 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $2,454 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $31,924 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $2,454 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	1
Insurance contract or identification number ETB146031 Number of Individuals Covered 1253 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	2
Insurance contract or identification number 12279876 Number of Individuals Covered 928 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $115,042 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5916707
Policy instance	7
Insurance contract or identification number 5916707 Number of Individuals Covered 2124 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $83,559 Total amount of fees paid to insurance company USD $18,348 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT,CRITICAL ILLNESS,HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $1,286,065 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83,559 Amount paid for insurance broker fees 18348 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	4
Insurance contract or identification number 70082-7 Number of Individuals Covered 2057 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $124,876 Total amount of fees paid to insurance company USD $0 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $1,228,758 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $124,876 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3342396
Policy instance	5
Insurance contract or identification number 3342396 Number of Individuals Covered 1769 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $254,806 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,159,933 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $254,806 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	6
Insurance contract or identification number 601235 Number of Individuals Covered 97 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $24,979 Total amount of fees paid to insurance company USD $558 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $1,077,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,979 Amount paid for insurance broker fees 558 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	14615
Policy instance	3
Insurance contract or identification number 14615 Number of Individuals Covered 1049 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $962 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $19,232 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $962 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	1
Insurance contract or identification number ETB146031 Number of Individuals Covered 1093 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $557 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $3,713 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $557 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	2
Insurance contract or identification number 12279876 Number of Individuals Covered 791 Insurance policy start date 2021-02-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $88,576 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3342396
Policy instance	4
Insurance contract or identification number 3342396 Number of Individuals Covered 1529 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $151,311 Total amount of fees paid to insurance company USD $7,992 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,969,822 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $151,311 Amount paid for insurance broker fees 7992 Additional information about fees paid to insurance broker SERVICE/GEN AGENT FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5916707
Policy instance	5
Insurance contract or identification number 5916707 Number of Individuals Covered 1759 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $50,707 Total amount of fees paid to insurance company USD $4,084 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT,CRITICAL ILLNESS,HOSPITAL Welfare Benefit Premiums Paid to Carrier USD $705,238 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,707 Amount paid for insurance broker fees 4084 Additional information about fees paid to insurance broker NON-MONETARY AND SUPPLEMANTAL COMPENSATION Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	6
Insurance contract or identification number 601235 Number of Individuals Covered 101 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $17,246 Total amount of fees paid to insurance company USD $267 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Welfare Benefit Premiums Paid to Carrier USD $512,434 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,246 Amount paid for insurance broker fees 267 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	7
Insurance contract or identification number 70082-7 Number of Individuals Covered 1722 Insurance policy start date 2021-05-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $67,716 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $681,661 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,716 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	3
Insurance contract or identification number ETB146031 Number of Individuals Covered 974 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $1,660 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $11,066 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $1,660 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	4
Insurance contract or identification number 12279876 Number of Individuals Covered 701 Insurance policy start date 2020-02-01 Insurance policy end date 2021-01-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $84,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5916707
Policy instance	2
Insurance contract or identification number 5916707 Number of Individuals Covered 2042 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $25,568 Total amount of fees paid to insurance company USD $2,667 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $732,604 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $25,568 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION ADDITIONAL COMPENSATION
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 102 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $27,035 Total amount of fees paid to insurance company USD $1,332 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $930,985 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,035 Amount paid for insurance broker fees 1332 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3342396
Policy instance	6
Insurance contract or identification number 3342396 Number of Individuals Covered 1350 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $188,714 Total amount of fees paid to insurance company USD $8,552 Health Insurance Welfare Benefit Yes Were dividends or retroactive rate refunds paid in cash? Yes Welfare Benefit Premiums Paid to Carrier USD $2,850,268 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $188,714 Amount paid for insurance broker fees 8552 Additional information about fees paid to insurance broker SERVICE/GEN. AGENT FEES Insurance broker organization code? 3
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	5
Insurance contract or identification number 14615 Number of Individuals Covered 955 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $1,347 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $28,279 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,347 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	7
Insurance contract or identification number 70082-7 Number of Individuals Covered 1602 Insurance policy start date 2020-05-01 Insurance policy end date 2021-04-30 Total amount of commissions paid to insurance broker USD $89,105 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $881,998 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $89,105 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 111 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $26,232 Total amount of fees paid to insurance company USD $1,831 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $914,849 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26,232 Amount paid for insurance broker fees 1831 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	5
Insurance contract or identification number 14615 Number of Individuals Covered 256 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $360 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $7,565 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $360 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	3
Insurance contract or identification number ETB146031 Number of Individuals Covered 1021 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	7
Insurance contract or identification number 70082-7 Number of Individuals Covered 1780 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $76,989 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $774,969 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $76,989 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3342396
Policy instance	6
Insurance contract or identification number 3342396 Number of Individuals Covered 1365 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $441,694 Total amount of fees paid to insurance company USD $33,198 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,445,552 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $441,694 Amount paid for insurance broker fees 33198 Additional information about fees paid to insurance broker SERVICE/GEN. AGENT FEES Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	4
Insurance contract or identification number 12279876 Number of Individuals Covered 730 Insurance policy start date 2019-02-01 Insurance policy end date 2020-01-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $78,981 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5916707
Policy instance	2
Insurance contract or identification number 5916707 Number of Individuals Covered 2153 Insurance policy start date 2019-05-01 Insurance policy end date 2020-04-30 Total amount of commissions paid to insurance broker USD $22,810 Total amount of fees paid to insurance company USD $12,362 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $850,169 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,810 Amount paid for insurance broker fees 12362 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	805840
Policy instance	3
Insurance contract or identification number 805840 Number of Individuals Covered 276 Insurance policy start date 2018-05-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $67,178 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,743,700 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,178 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	8
Insurance contract or identification number 70082-7 Number of Individuals Covered 1352 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $33,632 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $338,617 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $33,632 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	7
Insurance contract or identification number 14615 Number of Individuals Covered 256 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $804 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $16,071 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $804 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 213 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $0 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	6
Insurance contract or identification number 12279876 Number of Individuals Covered 338 Insurance policy start date 2018-02-01 Insurance policy end date 2019-01-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $31,330 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	5916707
Policy instance	4
Insurance contract or identification number 5916707 Number of Individuals Covered 1876 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $13,438 Total amount of fees paid to insurance company USD $3,406 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $418,471 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,438 Amount paid for insurance broker fees 3406 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	805840HNO
Policy instance	2
Insurance contract or identification number 805840HNO Number of Individuals Covered 80 Insurance policy start date 2018-05-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $15,383 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $390,138 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $15,383 Amount paid for insurance broker fees 0 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 115 Insurance policy start date 2018-05-01 Insurance policy end date 2019-04-30 Total amount of commissions paid to insurance broker USD $24,461 Total amount of fees paid to insurance company USD $1,468 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $866,017 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,461 Amount paid for insurance broker fees 1468 Additional information about fees paid to insurance broker BONUS Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	6
Insurance contract or identification number 12279876 Number of Individuals Covered 169 Insurance policy start date 2017-02-01 Insurance policy end date 2018-01-31 Total amount of commissions paid to insurance broker USD $1,351 Total amount of fees paid to insurance company USD $0 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $28,157 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,351 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	805840HNO
Policy instance	2
Insurance contract or identification number 805840HNO Number of Individuals Covered 81 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $21,529 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $545,355 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,529 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 207 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $505 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Welfare Benefit Premiums Paid to Carrier USD $3,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $505 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	7
Insurance contract or identification number 14615 Number of Individuals Covered 208 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $405 Total amount of fees paid to insurance company USD $0 Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $8,099 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $405 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 87 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $17,791 Total amount of fees paid to insurance company USD $1,907 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $671,065 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,791 Amount paid for insurance broker fees 1907 Additional information about fees paid to insurance broker BONUS NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number	70082-7
Policy instance	8
Insurance contract or identification number 70082-7 Number of Individuals Covered 277 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $18,006 Total amount of fees paid to insurance company USD $0 Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM Welfare Benefit Premiums Paid to Carrier USD $181,597 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,006 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	805840
Policy instance	3
Insurance contract or identification number 805840 Number of Individuals Covered 226 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $83,250 Total amount of fees paid to insurance company USD $220 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,110,869 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $83,250 Amount paid for insurance broker fees 220 Additional information about fees paid to insurance broker INDIRECT COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05916707
Policy instance	4
Insurance contract or identification number KM05916707 Number of Individuals Covered 685 Insurance policy start date 2017-05-01 Insurance policy end date 2018-04-30 Total amount of commissions paid to insurance broker USD $9,888 Total amount of fees paid to insurance company USD $4,959 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $270,043 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,888 Amount paid for insurance broker fees 4959 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	805840
Policy instance	3
Insurance contract or identification number 805840 Number of Individuals Covered 220 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $68,002 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,720,978 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $68,002 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	8
Insurance contract or identification number 14615 Number of Individuals Covered 197 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $383 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $8,040 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $383 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	7
Insurance contract or identification number ETB146031 Number of Individuals Covered 195 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT 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? Yes
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	01-016099-00
Policy instance	6
Insurance contract or identification number 01-016099-00 Number of Individuals Covered 198 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $16,127 Total amount of fees paid to insurance company USD $4,793 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $147,949 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,127 Amount paid for insurance broker fees 4793 Additional information about fees paid to insurance broker GROUP VOLUME BONUS Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	5
Insurance contract or identification number 12279876 Number of Individuals Covered 168 Insurance policy start date 2015-02-01 Insurance policy end date 2016-01-31 Total amount of commissions paid to insurance broker USD $1,297 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $26,376 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,297 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05916707
Policy instance	4
Insurance contract or identification number KM05916707 Number of Individuals Covered 420 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $10,344 Total amount of fees paid to insurance company USD $3,472 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $220,399 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,344 Amount paid for insurance broker fees 3472 Additional information about fees paid to insurance broker SUPPLEMENTARY COMPENSATION NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	805840HNO
Policy instance	2
Insurance contract or identification number 805840HNO Number of Individuals Covered 61 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $16,170 Total amount of fees paid to insurance company USD $2,800 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $408,752 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $16,170 Amount paid for insurance broker fees 2800 Additional information about fees paid to insurance broker 2014/2015 PPP ENGAGEMENT CREDIT Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 104 Insurance policy start date 2015-05-01 Insurance policy end date 2016-04-30 Total amount of commissions paid to insurance broker USD $20,904 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $720,457 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,904 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 198 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $505 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,364 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $505 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 109 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $21,907 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $757,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,907 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	6
Insurance contract or identification number 14615 Number of Individuals Covered 191 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $374 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $374 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	805840
Policy instance	2
Insurance contract or identification number 805840 Number of Individuals Covered 62 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $13,090 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $355,823 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,090 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	3
Insurance contract or identification number 12279876 Number of Individuals Covered 159 Insurance policy start date 2014-02-01 Insurance policy end date 2015-01-31 Total amount of commissions paid to insurance broker USD $1,192 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $22,864 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,192 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	01-016099-00
Policy instance	4
Insurance contract or identification number 01-016099-00 Number of Individuals Covered 198 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $13,805 Total amount of fees paid to insurance company USD $4,060 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $147,151 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $14,715 Amount paid for insurance broker fees 4060 Additional information about fees paid to insurance broker GROUP VOLUME BONUS Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	805840
Policy instance	7
Insurance contract or identification number 805840 Number of Individuals Covered 216 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $53,300 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,459,000 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,300 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05916707
Policy instance	8
Insurance contract or identification number KM05916707 Number of Individuals Covered 659 Insurance policy start date 2014-05-01 Insurance policy end date 2015-04-30 Total amount of commissions paid to insurance broker USD $7,843 Total amount of fees paid to insurance company USD $6,186 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $234,285 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,843 Amount paid for insurance broker fees 6186 Additional information about fees paid to insurance broker SUPPLEMENTARY COMPENSATION NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	152931
Policy instance	2
Insurance contract or identification number 152931 Number of Individuals Covered 238 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $38,231 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,549,772 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,352 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	01-016099
Policy instance	4
Insurance contract or identification number 01-016099 Number of Individuals Covered 177 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $10,883 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $108,833 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,137 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	3
Insurance contract or identification number 12279876 Number of Individuals Covered 141 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $1,159 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $20,060 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $593 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 166 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $296 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $296 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	6
Insurance contract or identification number 14615 Number of Individuals Covered 171 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $376 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,129 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $188 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	477902
Policy instance	7
Insurance contract or identification number 477902 Number of Individuals Covered 147 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $7,413 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $185,309 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $4,910 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 109 Insurance policy start date 2013-05-01 Insurance policy end date 2014-04-30 Total amount of commissions paid to insurance broker USD $14,236 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $720,929 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,979 Insurance broker organization code? 3 Insurance broker name ABD INS. AND FINANCIAL SVCS., INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	152931
Policy instance	2
Insurance contract or identification number 152931 Number of Individuals Covered 211 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $37,092 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,440,654 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	5
Insurance contract or identification number 12279876 Number of Individuals Covered 129 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $997 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,454 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	016099
Policy instance	6
Insurance contract or identification number 016099 Number of Individuals Covered 158 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $9,118 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $91,180 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	1
Insurance contract or identification number 601235 Number of Individuals Covered 101 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $17,277 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $454,992 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,277 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	152931
Policy instance	2
Insurance contract or identification number 152931 Number of Individuals Covered 211 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $37,092 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,440,547 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $37,092 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	3
Insurance contract or identification number 12279876 Number of Individuals Covered 129 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $997 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $17,454 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $997 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	016099
Policy instance	4
Insurance contract or identification number 016099 Number of Individuals Covered 158 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $9,118 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $91,180 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,118 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	1
Insurance contract or identification number 14615 Number of Individuals Covered 164 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $359 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PLAN Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	6
Insurance contract or identification number 14615 Number of Individuals Covered 164 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $359 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PLAN Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,176 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $359 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	4
Insurance contract or identification number 601235 Number of Individuals Covered 101 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $17,277 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $545,992 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	3
Insurance contract or identification number ETB146031 Number of Individuals Covered 162 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $178 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 162 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $178 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $178 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	477902
Policy instance	7
Insurance contract or identification number 477902 Number of Individuals Covered 133 Insurance policy start date 2012-05-01 Insurance policy end date 2013-04-30 Total amount of commissions paid to insurance broker USD $7,091 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $177,285 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $7,091 Insurance broker organization code? 3 Insurance broker name MERCER HEALTH AND BENEFITS, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	9
Insurance contract or identification number 12279876 Number of Individuals Covered 141 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $1,048 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $18,147 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number	881995-000-099
Policy instance	8
Insurance contract or identification number 881995-000-099 Number of Individuals Covered 311 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $7,299 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $181,860 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Number of Individuals Covered 171 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $178 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	881995-199 -100
Policy instance	7
Insurance contract or identification number 881995-199 -100 Number of Individuals Covered 24 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $163 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,205 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	6
Insurance contract or identification number 601235 Number of Individuals Covered 111 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $16,110 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $498,101 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	4
Insurance contract or identification number 14615 Number of Individuals Covered 163 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $356 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $7,128 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	152931
Policy instance	3
Insurance contract or identification number 152931 Number of Individuals Covered 46 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $8,892 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $270,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	152931
Policy instance	2
Insurance contract or identification number 152931 Number of Individuals Covered 169 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $2,166 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $65,801 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	152931
Policy instance	1
Insurance contract or identification number 152931 Number of Individuals Covered 169 Insurance policy start date 2011-05-01 Insurance policy end date 2012-04-30 Total amount of commissions paid to insurance broker USD $37,225 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,131,029 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	152931
Policy instance	1
Insurance contract or identification number 152931 Number of Individuals Covered 159 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $3,194 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $54,976 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	152931
Policy instance	3
Insurance contract or identification number 152931 Number of Individuals Covered 61 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $15,990 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $275,275 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CLAREMONT (National Association of Insurance Commissioners NAIC id number: 61171 )
Policy contract number	14615
Policy instance	4
Insurance contract or identification number 14615 Number of Individuals Covered 148 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $324 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided EMPLOYEE ASSISTANCE PROGRAM Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,486 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	ETB146031
Policy instance	5
Insurance contract or identification number ETB146031 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $178 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,184 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	601235
Policy instance	6
Insurance contract or identification number 601235 Number of Individuals Covered 101 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $11,356 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $451,695 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	881995-199 -100
Policy instance	7
Insurance contract or identification number 881995-199 -100 Number of Individuals Covered 28 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $190 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,299 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number	881995-000-099
Policy instance	8
Insurance contract or identification number 881995-000-099 Number of Individuals Covered 307 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $8,660 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $157,594 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	12279876
Policy instance	9
Insurance contract or identification number 12279876 Number of Individuals Covered 135 Insurance policy start date 2010-05-01 Insurance policy end date 2011-04-30 Total amount of commissions paid to insurance broker USD $1,029 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $16,997 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number	152931
Policy instance	2
Insurance contract or identification number 152931 Number of Individuals Covered 159 Insurance policy start date 2010-04-01 Insurance policy end date 2011-03-31 Total amount of commissions paid to insurance broker USD $51,705 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $890,111 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No