MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN
Plan identification number	575

MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

MANTECH INTERNATIONAL CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:	MANTECH INTERNATIONAL CORPORATION
Employer identification number (EIN):	221852179
NAIC Classification:	541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
575	2022-01-01	JULIE ANNA BARKER	2023-10-13
575	2021-01-01	JULIE ANNA BARKER	2022-10-17
575	2020-01-01	JULIE ANNA BARKER	2021-10-14
575	2019-01-01	JEFFREY S. BRODY	2020-07-28
575	2018-01-01	JEFFREY S. BRODY	2019-07-30
575	2017-01-01
575	2017-01-01
575	2016-01-01	DENISE GOODING
575	2016-01-01
575	2015-01-01	DENISE GOODING
575	2015-01-01
575	2014-01-01	DENISE GOODING		DENISE GOODING	2015-10-05
575	2013-01-01	DENISE GOODING
575	2012-01-01	DENISE GOODING
575	2011-01-01	DENISE GOODING
575	2009-01-01	DENISE GOODING

Plan Statistics for MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN

401k plan membership statisitcs for MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN

Measure	Date	Value
2022: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	7,885
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	8,923
Number of retired or separated participants receiving benefits	2022-01-01	61
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	8,984
2021: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	7,784
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	7,826
Number of retired or separated participants receiving benefits	2021-01-01	98
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	7,924
2020: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	8,085
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	8,444
Number of retired or separated participants receiving benefits	2020-01-01	122
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	8,566
2019: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	6,805
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	6,990
Number of retired or separated participants receiving benefits	2019-01-01	67
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	7,057
2018: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	6,442
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	6,762
Number of retired or separated participants receiving benefits	2018-01-01	43
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	6,805
2017: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	6,033
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	6,256
Number of retired or separated participants receiving benefits	2017-01-01	93
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	6,349
2016: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	6,716
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	5,992
Number of retired or separated participants receiving benefits	2016-01-01	41
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	6,033
2015: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	6,744
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	6,716
Number of retired or separated participants receiving benefits	2015-01-01	2
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	6,718
2014: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	6,571
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	6,952
Number of retired or separated participants receiving benefits	2014-01-01	440
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	7,392
2013: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	10,035
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	6,378
Number of retired or separated participants receiving benefits	2013-01-01	191
Number of other retired or separated participants entitled to future benefits	2013-01-01	2
Total of all active and inactive participants	2013-01-01	6,571
2012: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	9,937
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	9,189
Number of retired or separated participants receiving benefits	2012-01-01	159
Number of other retired or separated participants entitled to future benefits	2012-01-01	687
Total of all active and inactive participants	2012-01-01	10,035
2011: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	9,883
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	9,200
Number of retired or separated participants receiving benefits	2011-01-01	210
Number of other retired or separated participants entitled to future benefits	2011-01-01	527
Total of all active and inactive participants	2011-01-01	9,937
2009: MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	6,815
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	8,123
Number of retired or separated participants receiving benefits	2009-01-01	93
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	8,216

Form 5500 Responses for MANTECH CONSOLIDATED GROUP WELFARE BENEFIT PLAN

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

Insurance Providers Used on plan

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )
Policy contract number	201085
Policy instance	15
Insurance contract or identification number 201085 Number of Individuals Covered 1227 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $80,902 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 $6,922,208 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $80,902 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0229317
Policy instance	12
Insurance contract or identification number 0229317 Number of Individuals Covered 13271 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $152,456 Total amount of fees paid to insurance company USD $69,517 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 No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,572,652 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $152,456 Amount paid for insurance broker fees 69517 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION MARKETING FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0229312
Policy instance	13
Insurance contract or identification number 0229312 Number of Individuals Covered 8476 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $93,487 Total amount of fees paid to insurance company USD $42,970 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 Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,185,723 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $93,487 Amount paid for insurance broker fees 42970 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION MARKETING FEES Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	029002 004
Policy instance	14
Insurance contract or identification number 029002 004 Number of Individuals Covered 22 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $116,506 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-22
Policy instance	1
Insurance contract or identification number 4EL-7413-22 Number of Individuals Covered 723 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $130,990 Total amount of fees paid to insurance company USD $65,494 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 Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,274,537 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65,495 Amount paid for insurance broker fees 32747 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 1294 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $27,640 Total amount of fees paid to insurance company USD $4,946 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL SERVICES 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 $294,628 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $27,640 Amount paid for insurance broker fees 4940 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION MARKETING FEE Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	233630
Policy instance	3
Insurance contract or identification number 233630 Number of Individuals Covered 49 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $5,612 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 $544,086 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,612 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	24779
Policy instance	4
Insurance contract or identification number 24779 Number of Individuals Covered 275 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $26,309 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 $1,231,485 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26,309 Amount paid for insurance broker fees 1 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	50041
Policy instance	5
Insurance contract or identification number 50041 Number of Individuals Covered 5 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $1,088 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 $44,378 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,088 Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	11
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 2570 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $46,837 Total amount of fees paid to insurance company USD $35,127 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 VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $234,183 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $46,837 Insurance broker organization code? 3 Amount paid for insurance broker fees 35127 Additional information about fees paid to insurance broker GENERAL AGENT FEES SUPPLEMENTAL COMPENSATION
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	10
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 8363 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $6,075 Total amount of fees paid to insurance company USD $24,300 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $121,499 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 24300 Additional information about fees paid to insurance broker GENERAL AGENT FEES SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3 Commission paid to Insurance Broker USD $6,075
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	9
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 8923 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $25,630 Total amount of fees paid to insurance company USD $89,706 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 BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $512,603 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 89706 Additional information about fees paid to insurance broker GENERAL AGENT FEES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $25,630
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30078235
Policy instance	8
Insurance contract or identification number 30078235 Number of Individuals Covered 5353 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $140,956 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 $1,303,320 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $140,956 Insurance broker organization code? 3
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	000403589
Policy instance	7
Insurance contract or identification number 000403589 Number of Individuals Covered 67 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $3,325 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 $45,295 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,325 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000023668
Policy instance	6
Insurance contract or identification number 0000023668 Number of Individuals Covered 2963 Insurance policy start date 2022-01-01 Insurance policy end date 2022-12-31 Total amount of commissions paid to insurance broker USD $445,361 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 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 $1,761,813 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $445,361 Insurance broker organization code? 3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-21
Policy instance	1
Insurance contract or identification number 4EL-7413-21 Number of Individuals Covered 921 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $81,813 Total amount of fees paid to insurance company USD $40,906 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 $4,090,647 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $81,813 Insurance broker organization code? 3 Amount paid for insurance broker fees 40906 Additional information about fees paid to insurance broker ACCESS FEE
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	000403589
Policy instance	7
Insurance contract or identification number 000403589 Number of Individuals Covered 108 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $3,035 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 $45,571 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,035 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	50041
Policy instance	5
Insurance contract or identification number 50041 Number of Individuals Covered 12 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $1,209 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 $59,250 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,209 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	24779
Policy instance	4
Insurance contract or identification number 24779 Number of Individuals Covered 259 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $26,882 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 $1,299,141 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26,882 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	233630
Policy instance	3
Insurance contract or identification number 233630 Number of Individuals Covered 50 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,310 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 $496,185 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,310 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 1046 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $24,049 Total amount of fees paid to insurance company USD $5,195 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL SERVICES 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 $24,038 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,049 Amount paid for insurance broker fees 5195 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION MARKETING FEE Insurance broker organization code? 3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30078235
Policy instance	8
Insurance contract or identification number 30078235 Number of Individuals Covered 4724 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $111,833 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 $1,214,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? Yes Commission paid to Insurance Broker USD $111,833 Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	9
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 8336 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $12,351 Total amount of fees paid to insurance company USD $98,810 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $494,051 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 98810 Additional information about fees paid to insurance broker GENERAL AGENT FEES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $12,351
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000023668
Policy instance	6
Insurance contract or identification number 0000023668 Number of Individuals Covered 5526 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $215,551 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 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 $1,590,072 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $215,551 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	029002
Policy instance	14
Insurance contract or identification number 029002 Number of Individuals Covered 39 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $183,780 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0229312
Policy instance	13
Insurance contract or identification number 0229312 Number of Individuals Covered 7293 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $67,049 Total amount of fees paid to insurance company USD $29,582 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 Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,995,196 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67,049 Amount paid for insurance broker fees 29582 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION MARKETING FEES Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	11
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 2304 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $65,157 Total amount of fees paid to insurance company USD $32,578 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 VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $325,876 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $65,157 Insurance broker organization code? 3 Amount paid for insurance broker fees 32578 Additional information about fees paid to insurance broker GENERAL AGENT FEES
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0229317
Policy instance	12
Insurance contract or identification number 0229317 Number of Individuals Covered 11380 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $107,284 Total amount of fees paid to insurance company USD $47,316 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 No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,189,660 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $107,284 Amount paid for insurance broker fees 47316 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION MARKETING FEES Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	10
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 7351 Insurance policy start date 2021-01-01 Insurance policy end date 2021-12-31 Total amount of commissions paid to insurance broker USD $5,972 Total amount of fees paid to insurance company USD $17,917 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $119,448 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 17917 Additional information about fees paid to insurance broker GENERAL AGENT FEES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $5,972
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	910624
Policy instance	13
Insurance contract or identification number 910624 Number of Individuals Covered 73 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $549 Total amount of fees paid to insurance company USD $172 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 $14,687 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $549 Amount paid for insurance broker fees 172 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	910623
Policy instance	12
Insurance contract or identification number 910623 Number of Individuals Covered 11621 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $234,735 Total amount of fees paid to insurance company USD $73,355 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 Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,407,824 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $234,735 Amount paid for insurance broker fees 73355 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	11
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 2975 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $50,784 Total amount of fees paid to insurance company USD $25,392 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $253,920 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,784 Insurance broker organization code? 3 Amount paid for insurance broker fees 25392 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	9
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $12,642 Total amount of fees paid to insurance company USD $80,910 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 BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $505,685 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 80910 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $12,642
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30078235
Policy instance	8
Insurance contract or identification number 30078235 Number of Individuals Covered 5287 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $114,844 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 $1,268,554 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $114,844 Insurance broker organization code? 3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-20
Policy instance	1
Insurance contract or identification number 4EL-7413-20 Number of Individuals Covered 957 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $210,380 Total amount of fees paid to insurance company USD $157,786 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 $5,259,507 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $105,190 Amount paid for insurance broker fees 78893 Additional information about fees paid to insurance broker ACCESS FEE Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000023668
Policy instance	6
Insurance contract or identification number 0000023668 Number of Individuals Covered 5172 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $318,387 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 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 $1,437,286 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $318,387 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	50041
Policy instance	5
Insurance contract or identification number 50041 Number of Individuals Covered 7 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $837 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 $46,861 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $837 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	24779
Policy instance	4
Insurance contract or identification number 24779 Number of Individuals Covered 316 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $24,643 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 $1,322,367 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $24,643 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	233630
Policy instance	3
Insurance contract or identification number 233630 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 $4,153 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 $207,729 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,153 Insurance broker organization code? 3
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 1084 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $23,376 Total amount of fees paid to insurance company USD $3,435 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL SERVICES 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 $214,073 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $23,376 Amount paid for insurance broker fees 3433 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	10
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 8444 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $4,480 Total amount of fees paid to insurance company USD $13,439 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $89,592 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 13439 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $4,480
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	000403589
Policy instance	7
Insurance contract or identification number 000403589 Number of Individuals Covered 66 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Total amount of commissions paid to insurance broker USD $1,965 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 $32,098 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,965 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	029002
Policy instance	14
Insurance contract or identification number 029002 Number of Individuals Covered 30 Insurance policy start date 2020-01-01 Insurance policy end date 2020-12-31 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $138,222 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	233630
Policy instance	3
Insurance contract or identification number 233630 Number of Individuals Covered 25 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $5,082 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 $252,262 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $5,082 Insurance broker organization code? 3
DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )
Policy contract number	000403589
Policy instance	8
Insurance contract or identification number 000403589 Number of Individuals Covered 65 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $3,121 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 $38,763 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,121 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	605649
Policy instance	6
Insurance contract or identification number 605649 Number of Individuals Covered 0 Insurance policy start date 2019-01-01 Insurance policy end date 2019-11-30 Total amount of commissions paid to insurance broker USD $67 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 $-163,086 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $67 Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	11
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 6682 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $4,406 Total amount of fees paid to insurance company USD $13,217 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $88,114 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 13217 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $4,406
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	30078235
Policy instance	9
Insurance contract or identification number 30078235 Number of Individuals Covered 4781 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $98,401 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 $1,087,044 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $98,401 Insurance broker organization code? 3
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	10
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $12,567 Total amount of fees paid to insurance company USD $75,402 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 BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $502,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 75402 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $12,567
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	12
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 2976 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $50,784 Total amount of fees paid to insurance company USD $25,392 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $253,920 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,784 Insurance broker organization code? 3 Amount paid for insurance broker fees 25392 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	910623
Policy instance	13
Insurance contract or identification number 910623 Number of Individuals Covered 7030 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $189,693 Total amount of fees paid to insurance company USD $63,625 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 Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,273,139 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $189,693 Amount paid for insurance broker fees 63625 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	910624
Policy instance	14
Insurance contract or identification number 910624 Number of Individuals Covered 67 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $439 Total amount of fees paid to insurance company USD $148 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 $10,971 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $439 Amount paid for insurance broker fees 148 Additional information about fees paid to insurance broker ADDITIONAL COMPENSATION Insurance broker organization code? 3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-18
Policy instance	1
Insurance contract or identification number 4EL-7413-18 Number of Individuals Covered 1033 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $108,939 Total amount of fees paid to insurance company USD $82,004 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 $5,466,953 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $108,939 Insurance broker organization code? 3 Amount paid for insurance broker fees 82004 Additional information about fees paid to insurance broker ACCESS FEE
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 1013 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $20,891 Total amount of fees paid to insurance company USD $2,619 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 PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $209,638 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,891 Amount paid for insurance broker fees 2598 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000023668
Policy instance	7
Insurance contract or identification number 0000023668 Number of Individuals Covered 3867 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $467,641 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 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 $1,281,466 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $467,641 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	24779
Policy instance	4
Insurance contract or identification number 24779 Number of Individuals Covered 154 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $34,528 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 $1,749,105 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $34,528 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	50041
Policy instance	5
Insurance contract or identification number 50041 Number of Individuals Covered 5 Insurance policy start date 2019-01-01 Insurance policy end date 2019-12-31 Total amount of commissions paid to insurance broker USD $960 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 $47,806 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $960 Insurance broker organization code? 3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-16
Policy instance	1
Insurance contract or identification number 4EL-7413-16 Number of Individuals Covered 789 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $79,701 Total amount of fees paid to insurance company USD $60,672 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 $4,044,409 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $79,701 Insurance broker organization code? 3 Amount paid for insurance broker fees 60672 Additional information about fees paid to insurance broker ACCESS FEE Insurance broker name ANTHEM INSURANCE COMPANY
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 114 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,079 Total amount of fees paid to insurance company USD $34 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 PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $31,474 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,079 Amount paid for insurance broker fees 34 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name BENEPLACE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	3
Insurance contract or identification number 104332 Number of Individuals Covered 61 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $8,836 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 $295,952 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $8,836 Insurance broker organization code? 3 Insurance broker name MERCER
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	12
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 6032 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $28,031 Total amount of fees paid to insurance company USD $14,015 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $140,153 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,031 Insurance broker organization code? 3 Amount paid for insurance broker fees 14015 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker name REUBEN WARNER ASSOCIATES, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	11
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 6256 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $3,690 Total amount of fees paid to insurance company USD $11,071 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 ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $73,809 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 11071 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,690 Insurance broker name MERCER
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	10
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $13,767 Total amount of fees paid to insurance company USD $82,602 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 BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $550,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 82602 Additional information about fees paid to insurance broker MARKETING & ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Commission paid to Insurance Broker USD $13,767 Insurance broker name MERCER
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	9
Insurance contract or identification number 12296541 Number of Individuals Covered 4408 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $10,143 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 $1,018,101 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,143 Insurance broker organization code? 3 Insurance broker name MERCER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX 980278
Policy instance	8
Insurance contract or identification number FLX 980278 Number of Individuals Covered 0 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $95,148 Total amount of fees paid to insurance company USD $19,121 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 No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,184,334 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $95,148 Amount paid for insurance broker fees 19121 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSION Insurance broker organization code? 3 Insurance broker name MERCER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLK 980147
Policy instance	7
Insurance contract or identification number FLK 980147 Number of Individuals Covered 0 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $11,391 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 Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,944,264 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 11391 Additional information about fees paid to insurance broker SUPPLEMENTAL COMMISSION Insurance broker organization code? 3 Insurance broker name MERCER
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	5
Insurance contract or identification number 2999 Number of Individuals Covered 25 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $2,450 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 $118,969 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,450 Insurance broker organization code? 3 Insurance broker name MERCER
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	4
Insurance contract or identification number 1789 Number of Individuals Covered 479 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $73,509 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 $2,171,260 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $73,509 Insurance broker organization code? 3 Insurance broker name MERCER
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	603867
Policy instance	6
Insurance contract or identification number 603867 Number of Individuals Covered 1 Insurance policy start date 2017-01-01 Insurance policy end date 2017-11-30 Total amount of commissions paid to insurance broker USD $243 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 $8,595 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $243 Insurance broker organization code? 3 Insurance broker name MERCER
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU3809493
Policy instance	11
Insurance contract or identification number GTU3809493 Number of Individuals Covered 10916 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $12,967 Total amount of fees paid to insurance company USD $77,802 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 ACCIDENTAL DEATH AND DISMEMBERMENT BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $518,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 77802 Additional information about fees paid to insurance broker MARKETING AND ADMINISTRATION SERVICE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $12,967
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	5
Insurance contract or identification number 2999 Number of Individuals Covered 22 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,343 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $159,048 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,343 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	11
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $12,967 Total amount of fees paid to insurance company USD $77,802 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $518,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,967 Insurance broker organization code? 3 Amount paid for insurance broker fees 77802 Additional information about fees paid to insurance broker MARKETING AND ADMINISTRAION SERVICE Insurance broker name REUBEN WARNER ASSOCIATES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	10
Insurance contract or identification number 12296541 Number of Individuals Covered 4349 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,028,117 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980278
Policy instance	9
Insurance contract or identification number FLX980278 Number of Individuals Covered 9064 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $115,535 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No 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 $2,916,413 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $115,535 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLK980147
Policy instance	8
Insurance contract or identification number FLK980147 Number of Individuals Covered 4625 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,746,014 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK100076
Policy instance	7
Insurance contract or identification number LK100076 Number of Individuals Covered 5897 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $74,784 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	4
Insurance contract or identification number 1789 Number of Individuals Covered 578 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $103,914 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,626,551 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $103,914 Insurance broker organization code? 3 Insurance broker name AON CONSULTING, INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	3
Insurance contract or identification number 104332 Number of Individuals Covered 72 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $10,548 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $353,122 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,548 Insurance broker organization code? 3 Insurance broker name AON CONSULTING, INC.
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 135 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,512 Total amount of fees paid to insurance company USD $31 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating 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 PREPAID LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $34,469 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,512 Amount paid for insurance broker fees 31 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name BENEPLACE
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-15
Policy instance	1
Insurance contract or identification number 4EL-7413-15 Number of Individuals Covered 765 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $75,360 Total amount of fees paid to insurance company USD $94,200 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,768,013 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $75,360 Insurance broker organization code? 3 Amount paid for insurance broker fees 94200 Additional information about fees paid to insurance broker ACCESS FEE Insurance broker name ANTHEM NATIONAL ACCOUNT
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	12
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 6952 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $3,562 Total amount of fees paid to insurance company USD $10,686 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $71,237 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,562 Insurance broker organization code? 3 Amount paid for insurance broker fees 10686 Additional information about fees paid to insurance broker MARKETING AND ADMIN SERVICES Insurance broker name REUBEN WARNER ASSOCIATES, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	13
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 6075 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $30,478 Total amount of fees paid to insurance company USD $15,239 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $152,390 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $30,478 Insurance broker organization code? 3 Amount paid for insurance broker fees 15239 Additional information about fees paid to insurance broker MARKETING AND ADMIN SERVICES Insurance broker name REUBEN WARNER ASSOCIATES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	603867
Policy instance	6
Insurance contract or identification number 603867 Number of Individuals Covered 3 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $1,777 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $62,285 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,777 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	10
Insurance contract or identification number 104332 Number of Individuals Covered 77 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $11,598 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $378,718 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,598 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK100076
Policy instance	13
Insurance contract or identification number LK100076 Number of Individuals Covered 5688 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $52,368 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-14
Policy instance	1
Insurance contract or identification number 4EL-7413-14 Number of Individuals Covered 765 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $129,688 Total amount of fees paid to insurance company USD $162,093 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,484,380 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 162093 Additional information about fees paid to insurance broker ACCESS FEE Insurance broker organization code? 3 Insurance broker name AON CONSULTING
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	2
Insurance contract or identification number 1500129 Number of Individuals Covered 128 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,218 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $33,026 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,218 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name BENEPLACE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	603867
Policy instance	3
Insurance contract or identification number 603867 Number of Individuals Covered 12 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,071 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $86,482 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,071 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	6
Insurance contract or identification number 2999 Number of Individuals Covered 41 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $4,130 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $211,699 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,130 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	7
Insurance contract or identification number 12296541 Number of Individuals Covered 4272 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $10,700 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,700 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING, INC
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	11
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 6952 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $3,581 Total amount of fees paid to insurance company USD $10,742 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $71,611 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 10742 Additional information about fees paid to insurance broker MARKETING AND ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Insurance broker name AON RISK SERVICES, INC.
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	4
Insurance contract or identification number 1789 Number of Individuals Covered 593 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $111,630 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,717,076 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $111,630 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING, INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980278
Policy instance	5
Insurance contract or identification number FLX980278 Number of Individuals Covered 5856 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $113,385 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,039,452 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $113,385 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLK980147
Policy instance	8
Insurance contract or identification number FLK980147 Number of Individuals Covered 5679 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,095,307 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	9
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 4802 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $12,567 Total amount of fees paid to insurance company USD $75,402 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $502,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $0 Amount paid for insurance broker fees 75402 Additional information about fees paid to insurance broker MARKETING AND ADMINISTRATIVE SERVICES Insurance broker organization code? 3 Insurance broker name AON RISK SOLUTIONS, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	12
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 7312 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $32,743 Total amount of fees paid to insurance company USD $16,372 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $163,716 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $32,743 Amount paid for insurance broker fees 0 Insurance broker organization code? 3 Additional information about fees paid to insurance broker MARKETING AND ADMINISTRATIVE SERVICES Insurance broker name REUBEN WARNER ASSOCIATES, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	TDI980097
Policy instance	11
Insurance contract or identification number TDI980097 Number of Individuals Covered 6980 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $8,479 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	2
Insurance contract or identification number 12296541 Number of Individuals Covered 4766 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $12,150 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $10,010 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	3
Insurance contract or identification number 2999 Number of Individuals Covered 39 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $1,812 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $156,556 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,812 Insurance broker organization code? 3 Insurance broker name AON CONSULTING
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	5
Insurance contract or identification number 104332 Number of Individuals Covered 93 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $11,898 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $407,259 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,006 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	7
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 7312 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $45,089 Total amount of fees paid to insurance company USD $22,544 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $225,445 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $36,773 Insurance broker organization code? 3 Amount paid for insurance broker fees 22544 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SERVICES PERFORMED ON ZURICH BEHALF Insurance broker name WILLIS OF MARYLAND, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	6
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $12,567 Total amount of fees paid to insurance company USD $75,402 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $502,680 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 75402 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SRVCS PERFORMED ON ZURICH'S BEHALF Insurance broker organization code? 3 Commission paid to Insurance Broker USD $10,472 Insurance broker name WILLIS OF MARYLAND, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLK980147
Policy instance	8
Insurance contract or identification number FLK980147 Number of Individuals Covered 6980 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,982,732 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980278
Policy instance	9
Insurance contract or identification number FLX980278 Number of Individuals Covered 6980 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $135,776 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,012,631 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $109,525 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND INC
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number	4EL-7413-14
Policy instance	12
Insurance contract or identification number 4EL-7413-14 Number of Individuals Covered 1042 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $313,601 Total amount of fees paid to insurance company USD $392,001 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $15,680,024 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 392001 Additional information about fees paid to insurance broker ACCESS FEE Insurance broker organization code? 3 Commission paid to Insurance Broker USD $220,019 Insurance broker name WILLIS OF MD.
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	15
Insurance contract or identification number 1789 Number of Individuals Covered 778 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $118,403 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $3,232,743 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $94,346 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	603867
Policy instance	4
Insurance contract or identification number 603867 Number of Individuals Covered 29 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $5,176 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $177,905 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,875 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	F8523
Policy instance	14
Insurance contract or identification number F8523 Number of Individuals Covered 216 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $24,774 Total amount of fees paid to insurance company USD $59 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $201,493 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,547 Amount paid for insurance broker fees 41 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name RND FINANCIAL ASSOCIATES INC
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	13
Insurance contract or identification number 1500129 Number of Individuals Covered 134 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $3,150 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $30,041 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,150 Insurance broker organization code? 3 Insurance broker name BENEPLACE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 100076
Policy instance	10
Insurance contract or identification number LK 100076 Number of Individuals Covered 6980 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit 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 $9,169 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	1
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 6952 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $4,076 Total amount of fees paid to insurance company USD $12,227 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT AND BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $81,515 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 12227 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SERVICES PERFORMED ON ZURICH BEHALF Insurance broker organization code? 3 Commission paid to Insurance Broker USD $3,367 Insurance broker name WILLIS OF MARYLAND, INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848368
Policy instance	15
Insurance contract or identification number GTU 4848368 Number of Individuals Covered 7919 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $42,110 Total amount of fees paid to insurance company USD $14,320 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $210,552 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $42,110 Insurance broker organization code? 3 Amount paid for insurance broker fees 14320 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SERVICES PERFORMED ON ZURICH BEHALF Insurance broker name REUBEN WARNER ASSOCIATES, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675814G
Policy instance	3
Insurance contract or identification number 675814G Number of Individuals Covered 8258 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $122,675 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,344,625 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $122,675 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND INC
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	4
Insurance contract or identification number 1500129 Number of Individuals Covered 130 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $3,253 Total amount of fees paid to insurance company USD $26 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $32,585 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,253 Amount paid for insurance broker fees 26 Additional information about fees paid to insurance broker NON-MONETARY COMPENSATION Insurance broker organization code? 3 Insurance broker name BENEPLACE
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	75487-LTC
Policy instance	5
Insurance contract or identification number 75487-LTC Number of Individuals Covered 97 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $7,223 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LONG TERM CARE Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $144,456 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $7,223 Insurance broker organization code? 3 Insurance broker name BENEPLACE INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367
Policy instance	6
Insurance contract or identification number GTU 4848367 Number of Individuals Covered 8195 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $4,206 Total amount of fees paid to insurance company USD $8,683 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH & DISMEMBERMENT AND BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $84,127 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 8683 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SERVICES PERFORMED ON ZURICH BEHALF Insurance broker organization code? 3 Commission paid to Insurance Broker USD $4,206 Insurance broker name WILLIS OF MARYLAND, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	7
Insurance contract or identification number 12296541 Number of Individuals Covered 4946 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $12,623 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,623 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	9
Insurance contract or identification number 1789 Number of Individuals Covered 315 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $394,788 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,011,418 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $394,788 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	603867
Policy instance	10
Insurance contract or identification number 603867 Number of Individuals Covered 32 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $2,743 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $103,710 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $2,743 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	11
Insurance contract or identification number 104332 Number of Individuals Covered 85 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $9,961 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $364,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,961 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
S & W HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95099 )
Policy contract number	001068
Policy instance	12
Insurance contract or identification number 001068 Number of Individuals Covered 167 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $943,561 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	TS05463104
Policy instance	13
Insurance contract or identification number TS05463104 Number of Individuals Covered 112 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $4,755 Total amount of fees paid to insurance company USD $3,090 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $47,548 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,755 Amount paid for insurance broker fees 3090 Additional information about fees paid to insurance broker ADMIN FEES Insurance broker organization code? 5 Insurance broker name SCOTT & WHITE HEALTH PLAN INC.
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 3809493
Policy instance	14
Insurance contract or identification number GTU 3809493 Number of Individuals Covered 10916 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $12,697 Total amount of fees paid to insurance company USD $43,985 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided BUSINESS TRAVEL ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $507,880 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 43985 Additional information about fees paid to insurance broker ZURICH PAYS A FEE TO REUBEN WARNER FOR MARKETING AND ADMINISTRATIVE SERVICES PERFORMED ON ZURICH'S BEHA Insurance broker organization code? 3 Commission paid to Insurance Broker USD $12,697 Insurance broker name WILLIS OF MARYLAND, INC.
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00486A
Policy instance	2
Insurance contract or identification number 00486A Number of Individuals Covered 1630 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $387,696 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $19,384,794 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $387,696 Insurance broker organization code? 3 Insurance broker name WILLIS OF MARYLAND, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	8
Insurance contract or identification number 2999 Number of Individuals Covered 27 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $108,973 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	F8523
Policy instance	1
Insurance contract or identification number F8523 Number of Individuals Covered 288 Insurance policy start date 2012-01-01 Insurance policy end date 2012-12-31 Total amount of commissions paid to insurance broker USD $46,270 Total amount of fees paid to insurance company USD $615 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $240,925 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $22,038 Amount paid for insurance broker fees 218 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3 Insurance broker name JEFFREY SCOTT GIBSON
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	F8523
Policy instance	1
Insurance contract or identification number F8523 Number of Individuals Covered 318 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $41,540 Total amount of fees paid to insurance company USD $1,250 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $258,832
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00486A
Policy instance	2
Insurance contract or identification number 00486A Number of Individuals Covered 1401 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $295,617 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $14,780,839 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675814G
Policy instance	3
Insurance contract or identification number 675814G Number of Individuals Covered 8172 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $274,491 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,508,907 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	4
Insurance contract or identification number 1500129 Number of Individuals Covered 141 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $3,793 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL ASSISTANCE 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 $41,719 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	5
Insurance contract or identification number 2999 Number of Individuals Covered 15 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $64,732 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	7
Insurance contract or identification number 104332 Number of Individuals Covered 40 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $16,181 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $299,074 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
S & W HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95099 )
Policy contract number	001608
Policy instance	9
Insurance contract or identification number 001608 Number of Individuals Covered 108 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $1,357,079 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	10
Insurance contract or identification number 12296541 Number of Individuals Covered 5142 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $13,265 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367*
Policy instance	11
Insurance contract or identification number GTU 4848367* Number of Individuals Covered 9200 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $155,640 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, AND BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $932,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	6
Insurance contract or identification number 1789 Number of Individuals Covered 265 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $85,620 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,171,608 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	75487-LTC
Policy instance	8
Insurance contract or identification number 75487-LTC Number of Individuals Covered 107 Insurance policy start date 2011-01-01 Insurance policy end date 2011-12-31 Total amount of commissions paid to insurance broker USD $7,788 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LONG-TERM CARE Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $155,751 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 )
Policy contract number	12296541
Policy instance	10
Insurance contract or identification number 12296541 Number of Individuals Covered 5753 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $10,976 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	00486A
Policy instance	2
Insurance contract or identification number 00486A Number of Individuals Covered 1386 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $226,891 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit Yes Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $11,344,565 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number	1500129
Policy instance	4
Insurance contract or identification number 1500129 Number of Individuals Covered 173 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $4,247 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LEGAL ASSISTANCE 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 $38,761 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	675814G
Policy instance	3
Insurance contract or identification number 675814G Number of Individuals Covered 8228 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $226,505 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $4,839,135 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	2999
Policy instance	5
Insurance contract or identification number 2999 Number of Individuals Covered 16 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $75,901 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract number	F8523
Policy instance	1
Insurance contract or identification number F8523 Number of Individuals Covered 375 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $40,744 Total amount of fees paid to insurance company USD $1,508 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $291,955 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )
Policy contract number	1789
Policy instance	6
Insurance contract or identification number 1789 Number of Individuals Covered 220 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $77,151 Total amount of fees paid to insurance company USD $168 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,727,831 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	104332
Policy instance	7
Insurance contract or identification number 104332 Number of Individuals Covered 32 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $233,588 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number	75487-LTC
Policy instance	8
Insurance contract or identification number 75487-LTC Number of Individuals Covered 104 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $6,859 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided LONG-TERM CARE Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $137,189 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
S & W HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95099 )
Policy contract number	001608
Policy instance	9
Insurance contract or identification number 001608 Number of Individuals Covered 173 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $1,339,231 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
ZURICH AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 16535 )
Policy contract number	GTU 4848367*
Policy instance	11
Insurance contract or identification number GTU 4848367* Number of Individuals Covered 8567 Insurance policy start date 2010-01-01 Insurance policy end date 2010-12-31 Total amount of commissions paid to insurance broker USD $161,619 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT, AND BUSINESS TRAVEL ACCIDENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $969,062 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No