REVOLUTION FOODS has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan REVOLUTION FOODS HEALTH AND WELFARE PLAN
Measure | Date | Value |
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2022: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-11-01 | 764 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-11-01 | 571 |
Number of retired or separated participants receiving benefits | 2022-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-11-01 | 0 |
Total of all active and inactive participants | 2022-11-01 | 571 |
Number of employers contributing to the scheme | 2022-11-01 | 0 |
2021: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-11-01 | 688 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-11-01 | 750 |
Number of retired or separated participants receiving benefits | 2021-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-11-01 | 0 |
Total of all active and inactive participants | 2021-11-01 | 750 |
Number of employers contributing to the scheme | 2021-11-01 | 0 |
2020: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-11-01 | 823 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-11-01 | 692 |
Number of retired or separated participants receiving benefits | 2020-11-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2020-11-01 | 226 |
Total of all active and inactive participants | 2020-11-01 | 920 |
2019: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-11-01 | 1,123 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-11-01 | 957 |
Number of retired or separated participants receiving benefits | 2019-11-01 | 51 |
Number of other retired or separated participants entitled to future benefits | 2019-11-01 | 348 |
Total of all active and inactive participants | 2019-11-01 | 1,356 |
2018: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-11-01 | 1,443 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-11-01 | 1,136 |
Number of retired or separated participants receiving benefits | 2018-11-01 | 38 |
Number of other retired or separated participants entitled to future benefits | 2018-11-01 | 109 |
Total of all active and inactive participants | 2018-11-01 | 1,283 |
2017: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-11-01 | 1,320 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-11-01 | 1,233 |
Number of retired or separated participants receiving benefits | 2017-11-01 | 6 |
Number of other retired or separated participants entitled to future benefits | 2017-11-01 | 169 |
Total of all active and inactive participants | 2017-11-01 | 1,408 |
2016: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-11-01 | 1,217 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-11-01 | 1,162 |
Number of retired or separated participants receiving benefits | 2016-11-01 | 8 |
Number of other retired or separated participants entitled to future benefits | 2016-11-01 | 34 |
Total of all active and inactive participants | 2016-11-01 | 1,204 |
2015: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-11-01 | 1,105 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-11-01 | 1,168 |
Number of retired or separated participants receiving benefits | 2015-11-01 | 6 |
Number of other retired or separated participants entitled to future benefits | 2015-11-01 | 43 |
Total of all active and inactive participants | 2015-11-01 | 1,217 |
2014: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-11-01 | 680 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 504 |
Number of retired or separated participants receiving benefits | 2014-11-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2014-11-01 | 19 |
Total of all active and inactive participants | 2014-11-01 | 524 |
2013: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-11-01 | 585 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 675 |
Number of retired or separated participants receiving benefits | 2013-11-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2013-11-01 | 0 |
Total of all active and inactive participants | 2013-11-01 | 680 |
2012: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-11-01 | 284 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 224 |
Number of retired or separated participants receiving benefits | 2012-11-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2012-11-01 | 0 |
Total of all active and inactive participants | 2012-11-01 | 226 |
2011: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-11-01 | 284 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 224 |
Number of retired or separated participants receiving benefits | 2011-11-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 0 |
Total of all active and inactive participants | 2011-11-01 | 226 |
2010: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-11-01 | 122 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-11-01 | 160 |
Number of retired or separated participants receiving benefits | 2010-11-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2010-11-01 | 0 |
Total of all active and inactive participants | 2010-11-01 | 160 |
2009: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-11-01 | 101 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 120 |
Number of retired or separated participants receiving benefits | 2009-11-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2009-11-01 | 1 |
Total of all active and inactive participants | 2009-11-01 | 122 |
2022: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2022 form 5500 responses |
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2022-11-01 | Type of plan entity | Single employer plan |
2022-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2022-11-01 | Plan funding arrangement – Insurance | Yes |
2022-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-11-01 | Plan benefit arrangement – Insurance | Yes |
2022-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2021 form 5500 responses |
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2021-11-01 | Type of plan entity | Single employer plan |
2021-11-01 | Plan funding arrangement – Insurance | Yes |
2021-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-11-01 | Plan benefit arrangement – Insurance | Yes |
2021-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2020 form 5500 responses |
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2020-11-01 | Type of plan entity | Single employer plan |
2020-11-01 | Submission has been amended | No |
2020-11-01 | This submission is the final filing | No |
2020-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-11-01 | Plan is a collectively bargained plan | No |
2020-11-01 | Plan funding arrangement – Insurance | Yes |
2020-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-11-01 | Plan benefit arrangement – Insurance | Yes |
2020-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2019 form 5500 responses |
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2019-11-01 | Type of plan entity | Single employer plan |
2019-11-01 | Submission has been amended | No |
2019-11-01 | This submission is the final filing | No |
2019-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-11-01 | Plan is a collectively bargained plan | No |
2019-11-01 | Plan funding arrangement – Insurance | Yes |
2019-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-11-01 | Plan benefit arrangement – Insurance | Yes |
2019-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2018 form 5500 responses |
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2018-11-01 | Type of plan entity | Single employer plan |
2018-11-01 | Submission has been amended | No |
2018-11-01 | This submission is the final filing | No |
2018-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-11-01 | Plan is a collectively bargained plan | No |
2018-11-01 | Plan funding arrangement – Insurance | Yes |
2018-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-11-01 | Plan benefit arrangement – Insurance | Yes |
2018-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2017 form 5500 responses |
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2017-11-01 | Type of plan entity | Single employer plan |
2017-11-01 | Submission has been amended | No |
2017-11-01 | This submission is the final filing | No |
2017-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-11-01 | Plan is a collectively bargained plan | No |
2017-11-01 | Plan funding arrangement – Insurance | Yes |
2017-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-11-01 | Plan benefit arrangement – Insurance | Yes |
2017-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2016 form 5500 responses |
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2016-11-01 | Type of plan entity | Single employer plan |
2016-11-01 | Submission has been amended | No |
2016-11-01 | This submission is the final filing | No |
2016-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-11-01 | Plan is a collectively bargained plan | No |
2016-11-01 | Plan funding arrangement – Insurance | Yes |
2016-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-11-01 | Plan benefit arrangement – Insurance | Yes |
2016-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2015 form 5500 responses |
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2015-11-01 | Type of plan entity | Single employer plan |
2015-11-01 | Submission has been amended | No |
2015-11-01 | This submission is the final filing | No |
2015-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-11-01 | Plan is a collectively bargained plan | No |
2015-11-01 | Plan funding arrangement – Insurance | Yes |
2015-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-11-01 | Plan benefit arrangement – Insurance | Yes |
2015-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2014 form 5500 responses |
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2014-11-01 | Type of plan entity | Single employer plan |
2014-11-01 | Submission has been amended | No |
2014-11-01 | This submission is the final filing | No |
2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-11-01 | Plan is a collectively bargained plan | No |
2014-11-01 | Plan funding arrangement – Insurance | Yes |
2014-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-11-01 | Plan benefit arrangement – Insurance | Yes |
2014-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2013 form 5500 responses |
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2013-11-01 | Type of plan entity | Single employer plan |
2013-11-01 | Submission has been amended | No |
2013-11-01 | This submission is the final filing | No |
2013-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-11-01 | Plan is a collectively bargained plan | No |
2013-11-01 | Plan funding arrangement – Insurance | Yes |
2013-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-11-01 | Plan benefit arrangement – Insurance | Yes |
2013-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2012 form 5500 responses |
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2012-11-01 | Type of plan entity | Single employer plan |
2012-11-01 | Submission has been amended | No |
2012-11-01 | This submission is the final filing | No |
2012-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-11-01 | Plan is a collectively bargained plan | No |
2012-11-01 | Plan funding arrangement – Insurance | Yes |
2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-11-01 | Plan benefit arrangement – Insurance | Yes |
2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2011 form 5500 responses |
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2011-11-01 | Type of plan entity | Single employer plan |
2011-11-01 | Submission has been amended | No |
2011-11-01 | This submission is the final filing | No |
2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-11-01 | Plan is a collectively bargained plan | No |
2011-11-01 | Plan funding arrangement – Insurance | Yes |
2011-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-11-01 | Plan benefit arrangement – Insurance | Yes |
2011-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2010: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2010 form 5500 responses |
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2010-11-01 | Type of plan entity | Single employer plan |
2010-11-01 | Submission has been amended | No |
2010-11-01 | This submission is the final filing | No |
2010-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-11-01 | Plan is a collectively bargained plan | No |
2010-11-01 | Plan funding arrangement – Insurance | Yes |
2010-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2010-11-01 | Plan benefit arrangement – Insurance | Yes |
2010-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: REVOLUTION FOODS HEALTH AND WELFARE PLAN 2009 form 5500 responses |
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2009-11-01 | Type of plan entity | Single employer plan |
2009-11-01 | First time form 5500 has been submitted | Yes |
2009-11-01 | Submission has been amended | No |
2009-11-01 | This submission is the final filing | No |
2009-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-11-01 | Plan is a collectively bargained plan | No |
2009-11-01 | Plan funding arrangement – Insurance | Yes |
2009-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-11-01 | Plan benefit arrangement – Insurance | Yes |
2009-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 |
Policy instance | 6 |
Insurance contract or identification number | 143172 | Number of Individuals Covered | 434 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $20,357 | Total amount of fees paid to insurance company | USD $15,301,700 | 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,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $188,473 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,134 | Amount paid for insurance broker fees | 1700 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 127 | 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 $332 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,275,990 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 332 | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 472002 |
Policy instance | 2 |
Insurance contract or identification number | 472002 | Number of Individuals Covered | 189 | 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 $7,298 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $197,798 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 6653 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 3 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 170 | 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 $22,820 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 4 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 79 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $6,973 | Total amount of fees paid to insurance company | USD $825 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $23,720 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,655 | Amount paid for insurance broker fees | 611 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 |
Policy instance | 5 |
Insurance contract or identification number | 654799 | Number of Individuals Covered | 169 | 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 | 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 $1,830,387 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 |
Policy instance | 6 |
Insurance contract or identification number | 143172 | Number of Individuals Covered | 625 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $17,062 | Total amount of fees paid to insurance company | USD $4,076 | 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,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $204,979 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,777 | Amount paid for insurance broker fees | 1500 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 202 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $2,645 | Total amount of fees paid to insurance company | USD $4,642 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,561,121 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,645 | Amount paid for insurance broker fees | 4642 | Additional information about fees paid to insurance broker | 2020 PINNACLE MEDICAL RENTENTION INCENTIVE RISK, INDIRECT COMPENSATION | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 472002 |
Policy instance | 2 |
Insurance contract or identification number | 472002 | Number of Individuals Covered | 277 | Insurance policy start date | 2021-01-01 | 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 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $171,795 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 3 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 208 | Insurance policy start date | 2021-01-01 | 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 $26,676 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 4 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 64 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,467 | Total amount of fees paid to insurance company | USD $525 | Temporary Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $20,190 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,742 | Amount paid for insurance broker fees | 370 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 |
Policy instance | 5 |
Insurance contract or identification number | 654799 | Number of Individuals Covered | 161 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $705 | Total amount of fees paid to insurance company | USD $0 | 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 $795,840 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $705 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 228 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $40,782 | Total amount of fees paid to insurance company | USD $4,240 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,885,285 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $24,551 | Amount paid for insurance broker fees | 4240 | Additional information about fees paid to insurance broker | 2019 PREMIER PRODUCER PROGRAM - MEDICAL RETENTION RISK | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00472002 |
Policy instance | 2 |
Insurance contract or identification number | 00472002 | Number of Individuals Covered | 320 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $4,934 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $246,685 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,934 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 / 230856 |
Policy instance | 3 |
Insurance contract or identification number | 654799 / 230856 | Number of Individuals Covered | 146 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $22,237 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $950,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,237 | Insurance broker organization code? | 3 |
|
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 4 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 55 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $299 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $18,898 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $292 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0300731 |
Policy instance | 5 |
Insurance contract or identification number | R0300731 | Number of Individuals Covered | 130 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $524 | Total amount of fees paid to insurance company | USD $1 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | 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 | CRITICAL ILLNESS, ACCIDENT, HOSPITAL INDEMNITY | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $25,197 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $524 | Amount paid for insurance broker fees | 1 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 / 143173 |
Policy instance | 6 |
Insurance contract or identification number | 143172 / 143173 | Number of Individuals Covered | 573 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,621 | Total amount of fees paid to insurance company | USD $2,361 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, 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 $183,888 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,621 | Amount paid for insurance broker fees | 2361 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 7 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 244 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $231 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $29,359 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $231 | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 10 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 216 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $222 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $4,531 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $222 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 / 143173 |
Policy instance | 9 |
Insurance contract or identification number | 143172 / 143173 | Number of Individuals Covered | 196 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,492 | Total amount of fees paid to insurance company | USD $332 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, 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 $28,359 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,492 | Amount paid for insurance broker fees | 332 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0300731 |
Policy instance | 8 |
Insurance contract or identification number | R0300731 | Number of Individuals Covered | 133 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $51 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS, ACCIDENT, HOSPITAL | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,478 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $51 | Insurance broker organization code? | 3 |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 7 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 55 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $26 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,630 | 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 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
Policy contract number | 20718 |
Policy instance | 6 |
Insurance contract or identification number | 20718 | Number of Individuals Covered | 0 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $3,840 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $59,561 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,840 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
Policy contract number | 31559 |
Policy instance | 5 |
Insurance contract or identification number | 31559 | Number of Individuals Covered | 0 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $4,608 | Total amount of fees paid to insurance company | USD $55 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $90,491 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,608 | Amount paid for insurance broker fees | 55 | Additional information about fees paid to insurance broker | LBG BOB BONUS | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 / 230856 |
Policy instance | 4 |
Insurance contract or identification number | 654799 / 230856 | Number of Individuals Covered | 161 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $39,916 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,039,903 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $39,916 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00472002 |
Policy instance | 3 |
Insurance contract or identification number | 00472002 | Number of Individuals Covered | 309 | Insurance policy start date | 2019-11-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $5,313 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $53,129 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,313 | Insurance broker organization code? | 3 |
|
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
Policy contract number | 0805691HNO |
Policy instance | 2 |
Insurance contract or identification number | 0805691HNO | Number of Individuals Covered | 26 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $9,864 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $180,159 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,864 | Insurance broker organization code? | 3 |
|
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 177 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $87,936 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,613,063 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $87,936 | Insurance broker organization code? | 3 |
|
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 221 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $85,092 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,762,238 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $85,092 | Insurance broker organization code? | 3 |
|
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
Policy contract number | 0805691HNO |
Policy instance | 2 |
Insurance contract or identification number | 0805691HNO | Number of Individuals Covered | 32 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $14,830 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $291,839 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,830 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00472002 |
Policy instance | 3 |
Insurance contract or identification number | 00472002 | Number of Individuals Covered | 316 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $24,830 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $248,299 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $24,830 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 / 230856 |
Policy instance | 4 |
Insurance contract or identification number | 654799 / 230856 | Number of Individuals Covered | 199 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $50,159 | Total amount of fees paid to insurance company | USD $1 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,180,270 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $50,159 | Amount paid for insurance broker fees | 1 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
Policy contract number | 31559 |
Policy instance | 5 |
Insurance contract or identification number | 31559 | Number of Individuals Covered | 19 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $5,522 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $107,849 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,522 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
Policy contract number | 20718 |
Policy instance | 6 |
Insurance contract or identification number | 20718 | Number of Individuals Covered | 11 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,630 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $60,205 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,630 | Insurance broker organization code? | 3 |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 7 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 105 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $1,650 | Total amount of fees paid to insurance company | USD $123 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $33,619 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,639 | Amount paid for insurance broker fees | 123 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 / 143173 |
Policy instance | 9 |
Insurance contract or identification number | 143172 / 143173 | Number of Individuals Covered | 1010 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $10,585 | Total amount of fees paid to insurance company | USD $1,528 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, 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 $111,724 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,585 | Amount paid for insurance broker fees | 1528 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0300731 |
Policy instance | 8 |
Insurance contract or identification number | R0300731 | Number of Individuals Covered | 209 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $2,791 | Total amount of fees paid to insurance company | USD $205 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS, ACCIDENT, HOSPITAL | Were dividends 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 $40,950 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,791 | Amount paid for insurance broker fees | 205 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 10 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 228 | Insurance policy start date | 2018-11-01 | Insurance policy end date | 2019-10-31 | Total amount of commissions paid to insurance broker | USD $972 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $32,026 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $972 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 654799 / 230856 |
Policy instance | 5 |
Insurance contract or identification number | 654799 / 230856 | Number of Individuals Covered | 208 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $41,694 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,075,341 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00472002 |
Policy instance | 4 |
Insurance contract or identification number | 00472002 | Number of Individuals Covered | 369 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $25,931 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $259,313 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | R0300731 |
Policy instance | 3 |
Insurance contract or identification number | R0300731 | Number of Individuals Covered | 1 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $8 | Total amount of fees paid to insurance company | USD $1 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $45 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95109 ) |
Policy contract number | 0805691HNO |
Policy instance | 2 |
Insurance contract or identification number | 0805691HNO | Number of Individuals Covered | 13 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,106 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $57,573 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 ) |
Policy contract number | 20718 |
Policy instance | 7 |
Insurance contract or identification number | 20718 | Number of Individuals Covered | 10 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $4,200 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $64,035 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
Policy contract number | 31559 |
Policy instance | 6 |
Insurance contract or identification number | 31559 | Number of Individuals Covered | 24 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $4,637 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $89,906 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 8861265 |
Policy instance | 8 |
Insurance contract or identification number | 8861265 | Number of Individuals Covered | 188 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $5,358 | Total amount of fees paid to insurance company | USD $494 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $51,533 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0300731 |
Policy instance | 9 |
Insurance contract or identification number | R0300731 | Number of Individuals Covered | 442 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $8,390 | Total amount of fees paid to insurance company | USD $732 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CRITICAL ILLNESS, ACCIDENT, HOSPITAL | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $56,164 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 143172 / 143173 |
Policy instance | 10 |
Insurance contract or identification number | 143172 / 143173 | Number of Individuals Covered | 1340 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $9,699 | Total amount of fees paid to insurance company | USD $1,232 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, EAP | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $102,423 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30022186 |
Policy instance | 11 |
Insurance contract or identification number | 30022186 | Number of Individuals Covered | 255 | Insurance policy start date | 2017-11-01 | Insurance policy end date | 2018-10-31 | Total amount of commissions paid to insurance broker | USD $1,513 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $34,617 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 805691 |
Policy instance | 1 |
Insurance contract or identification number | 805691 | Number of Individuals Covered | 218 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $81,232 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,707,723 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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