BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN
Plan identification number	501

BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN Benefits

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

401k Sponsoring company profile

BAYADA HOME HEALTH CARE, INC. has sponsored the creation of one or more 401k plans.

Company Name:	BAYADA HOME HEALTH CARE, INC.
Employer identification number (EIN):	231943113
NAIC Classification:	621610
NAIC Description:	Home Health Care Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-07-01
501	2021-07-01
501	2020-07-01	MONICA ROLLO	2022-05-27
501	2019-07-01
501	2018-07-01
501	2017-07-01
501	2016-07-01	REKHA DANIEL
501	2015-07-01	MICHAEL ANZALONE
501	2014-07-01	MICHAEL ANZALONE
501	2013-07-01	TOM SIBSON
501	2012-07-01	KATHALEEN REAVY		KATHALEEN REAVY	2014-03-17
501	2011-07-01	PATTI MCLAUGHLIN		PATTI MCLAUGHLIN	2013-01-29
501	2010-07-01	PATTI MCLAUGHLIN
501	2009-07-01			PATTI MCLAUGHLIN	2011-03-28
501	2009-07-01	PATTI MCLAUGHLIN		PATTI MCLAUGHLIN	2011-03-28

Plan Statistics for BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN

Measure	Date	Value
2022: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	7,426
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	7,484
Number of retired or separated participants receiving benefits	2022-07-01	119
Number of other retired or separated participants entitled to future benefits	2022-07-01	816
Total of all active and inactive participants	2022-07-01	8,419
2021: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	8,535
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	8,676
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	775
Total of all active and inactive participants	2021-07-01	9,451
2020: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	19,180
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	19,021
Number of retired or separated participants receiving benefits	2020-07-01	56
Number of other retired or separated participants entitled to future benefits	2020-07-01	0
Total of all active and inactive participants	2020-07-01	19,077
2019: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	16,675
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	15,686
Number of retired or separated participants receiving benefits	2019-07-01	159
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	15,845
2018: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	13,220
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	16,551
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	16,551
2017: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	10,930
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	13,220
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	13,220
2016: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	10,481
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	10,865
Number of retired or separated participants receiving benefits	2016-07-01	69
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	10,934
2015: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-07-01	10,064
Total number of active participants reported on line 7a of the Form 5500	2015-07-01	10,435
Number of retired or separated participants receiving benefits	2015-07-01	46
Number of other retired or separated participants entitled to future benefits	2015-07-01	0
Total of all active and inactive participants	2015-07-01	10,481
2014: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-07-01	9,652
Total number of active participants reported on line 7a of the Form 5500	2014-07-01	9,983
Number of retired or separated participants receiving benefits	2014-07-01	81
Number of other retired or separated participants entitled to future benefits	2014-07-01	0
Total of all active and inactive participants	2014-07-01	10,064
2013: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-07-01	10,797
Total number of active participants reported on line 7a of the Form 5500	2013-07-01	9,606
Number of retired or separated participants receiving benefits	2013-07-01	46
Total of all active and inactive participants	2013-07-01	9,652
2012: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	8,866
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	10,742
Number of retired or separated participants receiving benefits	2012-07-01	55
Number of other retired or separated participants entitled to future benefits	2012-07-01	0
Total of all active and inactive participants	2012-07-01	10,797
2011: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-07-01	7,830
Total number of active participants reported on line 7a of the Form 5500	2011-07-01	8,812
Number of retired or separated participants receiving benefits	2011-07-01	54
Number of other retired or separated participants entitled to future benefits	2011-07-01	0
Total of all active and inactive participants	2011-07-01	8,866
2010: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-07-01	8,305
Total number of active participants reported on line 7a of the Form 5500	2010-07-01	7,830
Number of retired or separated participants receiving benefits	2010-07-01	41
Number of other retired or separated participants entitled to future benefits	2010-07-01	0
Total of all active and inactive participants	2010-07-01	7,871
2009: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	7,391
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	8,227
Number of retired or separated participants receiving benefits	2009-07-01	78
Number of other retired or separated participants entitled to future benefits	2009-07-01	0
Total of all active and inactive participants	2009-07-01	8,305

Form 5500 Responses for BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN

2022: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Submission has been amended	No
2020-07-01	This submission is the final filing	No
2020-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-07-01	Plan is a collectively bargained plan	No
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	Submission has been amended	Yes
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-07-01	Type of plan entity	Single employer plan
2015-07-01	Plan funding arrangement – Insurance	Yes
2015-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-07-01	Plan benefit arrangement – Insurance	Yes
2015-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-07-01	Type of plan entity	Single employer plan
2014-07-01	Plan funding arrangement – Insurance	Yes
2014-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-07-01	Plan benefit arrangement – Insurance	Yes
2014-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-07-01	Type of plan entity	Single employer plan
2013-07-01	Plan funding arrangement – Insurance	Yes
2013-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-07-01	Plan benefit arrangement – Insurance	Yes
2013-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	Submission has been amended	No
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-07-01	Type of plan entity	Single employer plan
2011-07-01	Submission has been amended	No
2011-07-01	This submission is the final filing	No
2011-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-07-01	Plan is a collectively bargained plan	No
2011-07-01	Plan funding arrangement – Insurance	Yes
2011-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-07-01	Plan benefit arrangement – Insurance	Yes
2011-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2010 form 5500 responses
2010-07-01	Type of plan entity	Single employer plan
2010-07-01	Submission has been amended	Yes
2010-07-01	This submission is the final filing	No
2010-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-07-01	Plan is a collectively bargained plan	No
2010-07-01	Plan funding arrangement – Insurance	Yes
2010-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-07-01	Plan benefit arrangement – Insurance	Yes
2010-07-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: BAYADA HOME HEALTH CARE INC. HEALTH & WELFARE PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	Submission has been amended	No
2009-07-01	This submission is the final filing	No
2009-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-07-01	Plan is a collectively bargained plan	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	4
Insurance contract or identification number FV1238 Number of Individuals Covered 2204 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $397,740 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 $945,750 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 318192 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	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 226 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 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 $1,703,446 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1003822
Policy instance	2
Insurance contract or identification number 1003822 Number of Individuals Covered 210 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $351 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 $14,159 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $351 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	020266, 022570
Policy instance	3
Insurance contract or identification number 020266, 022570 Number of Individuals Covered 246 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 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 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 $2,565,598 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	9767435
Policy instance	12
Insurance contract or identification number 9767435 Number of Individuals Covered 11871 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $19,727 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 $717,404 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,727 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	26803
Policy instance	5
Insurance contract or identification number 26803 Number of Individuals Covered 127 Insurance policy start date 2022-07-01 Insurance policy end date 2022-09-30 Total amount of commissions paid to insurance broker USD $493,800 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,076,504 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $246,900 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220579
Policy instance	6
Insurance contract or identification number 0220579 Number of Individuals Covered 807 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 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 $37,908 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	0236869
Policy instance	7
Insurance contract or identification number 0236869 Number of Individuals Covered 12 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $50 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 $914 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 45 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220261
Policy instance	8
Insurance contract or identification number 0220261 Number of Individuals Covered 80 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $118 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D, SUPPLEMENTAL LIFE, SUPPLEMENATL AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $13,160 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 118 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0233411
Policy instance	9
Insurance contract or identification number 0233411 Number of Individuals Covered 1721 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $10,250 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,060,078 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 10205 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	715097G
Policy instance	10
Insurance contract or identification number 715097G Number of Individuals Covered 4698 Insurance policy start date 2022-10-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $481,232 Total amount of fees paid to insurance company USD $123,722 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 Other welfare benefits provided ACCIDENT, HOSPITAL INDEMNITY, 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 $3,622,031 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $481,232 Insurance broker organization code? 3 Amount paid for insurance broker fees 123722 Additional information about fees paid to insurance broker FEES
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number	1039650
Policy instance	11
Insurance contract or identification number 1039650 Number of Individuals Covered 1 Insurance policy start date 2022-07-01 Insurance policy end date 2023-06-30 Total amount of commissions paid to insurance broker USD $1 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 $30 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 Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 248 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $29,327 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 $1,858,137 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $29,327 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	10038221001
Policy instance	2
Insurance contract or identification number 10038221001 Number of Individuals Covered 1135 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $21,215 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 $650,768 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,215 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266, 22570
Policy instance	3
Insurance contract or identification number 20266, 22570 Number of Individuals Covered 220 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 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 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 $2,412,240 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	26803
Policy instance	5
Insurance contract or identification number 26803 Number of Individuals Covered 6527 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $2,242,732 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,082,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $1,121,366 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220579
Policy instance	6
Insurance contract or identification number 0220579 Number of Individuals Covered 790 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 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 $65,431 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	0220261
Policy instance	7
Insurance contract or identification number 0220261 Number of Individuals Covered 55 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $66 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $6,644 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 66 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220261
Policy instance	8
Insurance contract or identification number 0220261 Number of Individuals Covered 18316 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $21,809 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,714,488 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 21809 Additional information about fees paid to insurance broker FEES Insurance broker organization code? 3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	4
Insurance contract or identification number FV1238 Number of Individuals Covered 2215 Insurance policy start date 2021-07-01 Insurance policy end date 2022-06-30 Total amount of commissions paid to insurance broker USD $429,990 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 $1,020,452 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $343,992 Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266, 22570
Policy instance	4
Insurance contract or identification number 20266, 22570 Number of Individuals Covered 348 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 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 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 $2,412,460 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	0220261
Policy instance	10
Insurance contract or identification number 0220261 Number of Individuals Covered 16743 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $12,540 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $1,688,207 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 12540 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 279 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $37,436 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 $1,962,741 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,750 Insurance broker organization code? 3
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09069
Policy instance	2
Insurance contract or identification number 09069 Number of Individuals Covered 12344 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 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 $3,815,900 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	10038221001
Policy instance	3
Insurance contract or identification number 10038221001 Number of Individuals Covered 11261 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $32,303 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 $683,172 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,406 Insurance broker organization code? 3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	5
Insurance contract or identification number FV1238 Number of Individuals Covered 3636 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $61,592 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 $1,231,837 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $61,592 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000026803
Policy instance	6
Insurance contract or identification number 0000026803 Number of Individuals Covered 9191 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $1,484,994 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 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 $4,061,788 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $742,497 Insurance broker organization code? 3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	10495-01
Policy instance	7
Insurance contract or identification number 10495-01 Number of Individuals Covered 62311 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $124,078 Are there contracts with allocated funds for individual policies? 0 Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $2,968,042 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 74625 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220579
Policy instance	8
Insurance contract or identification number 0220579 Number of Individuals Covered 449 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 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 $100,865 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	0220261A
Policy instance	9
Insurance contract or identification number 0220261A Number of Individuals Covered 36 Insurance policy start date 2020-07-01 Insurance policy end date 2021-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $39 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 Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided AD&D Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $5,329 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 39 Additional information about fees paid to insurance broker SUPPLEMENTAL COMPENSATION Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266, 22570
Policy instance	4
Insurance contract or identification number 20266, 22570 Number of Individuals Covered 256 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,638,020 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	1001
Policy instance	3
Insurance contract or identification number 1001 Number of Individuals Covered 10952 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $21,339 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $711,063 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $21,339 Insurance broker organization code? 3
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09069
Policy instance	2
Insurance contract or identification number 09069 Number of Individuals Covered 12048 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,483,563 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	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 197 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $58,672 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,687,522 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $58,672 Insurance broker organization code? 3
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	5
Insurance contract or identification number FV1238 Number of Individuals Covered 3912 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $60,876 Total amount of fees paid to insurance company USD $502,290 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,217,519 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $60,876 Amount paid for insurance broker fees 401832 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000021411
Policy instance	6
Insurance contract or identification number 0000021411 Number of Individuals Covered 13865 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $1,547,870 Health Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $5,483,293 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $773,935 Insurance broker organization code? 3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	10495-00
Policy instance	7
Insurance contract or identification number 10495-00 Number of Individuals Covered 5295 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $129,466 Welfare Benefit Premiums Paid to Carrier USD $2,589,327 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $129,466 Insurance broker organization code? 3
JOHN HANCOCK LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93610 )
Policy contract number	60017
Policy instance	8
Insurance contract or identification number 60017 Number of Individuals Covered 48 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Total amount of commissions paid to insurance broker USD $3,593 Other welfare benefits provided GROUP LONG-TERM CARE Welfare Benefit Premiums Paid to Carrier USD $57,404 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,593 Insurance broker organization code? 3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	0220579
Policy instance	9
Insurance contract or identification number 0220579 Number of Individuals Covered 449 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $34,054 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	0220261
Policy instance	10
Insurance contract or identification number 0220261 Number of Individuals Covered 15686 Insurance policy start date 2019-07-01 Insurance policy end date 2020-06-30 Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Other welfare benefits provided AD&D Welfare Benefit Premiums Paid to Carrier USD $1,486,831 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	TDI980089
Policy instance	9
Insurance contract or identification number TDI980089 Number of Individuals Covered 1058 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $2,544 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $209,019 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 2544 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980254
Policy instance	8
Insurance contract or identification number OK 980254 Number of Individuals Covered 16551 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $193 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $13,645 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 193 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 100053
Policy instance	7
Insurance contract or identification number LK 100053 Number of Individuals Covered 1504 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $6,216 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $437,642 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 6216 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980172
Policy instance	6
Insurance contract or identification number LK 980172 Number of Individuals Covered 1649 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $5,180 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $362,130 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 5180 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074852
Policy instance	10
Insurance contract or identification number NYD074852 Number of Individuals Covered 504 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $1,082 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $73,982 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1082 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266, 22570
Policy instance	11
Insurance contract or identification number 20266, 22570 Number of Individuals Covered 364 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,475,427 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	12
Insurance contract or identification number FV1238 Number of Individuals Covered 3148 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $50,344 Total amount of fees paid to insurance company USD $406,365 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,006,871 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $50,344 Amount paid for insurance broker fees 325092 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	4055950010SSLS
Policy instance	14
Insurance contract or identification number 4055950010SSLS Number of Individuals Covered 5109 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Welfare Benefit Premiums Paid to Carrier USD $2,775,480 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
JOHN HANCOCK LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93610 )
Policy contract number	60017
Policy instance	15
Insurance contract or identification number 60017 Number of Individuals Covered 50 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $9,599 Other welfare benefits provided GROUP LONG-TERM CARE Welfare Benefit Premiums Paid to Carrier USD $72,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $9,599 Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	97674351001
Policy instance	16
Insurance contract or identification number 97674351001 Number of Individuals Covered 10934 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $18,943 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $700,452 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $18,943 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980233
Policy instance	5
Insurance contract or identification number FLX980233 Number of Individuals Covered 16551 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $1,089 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $80,782 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1089 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980238
Policy instance	4
Insurance contract or identification number FLX980238 Number of Individuals Covered 2304 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of fees paid to insurance company USD $9,559 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $716,333 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 9559 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	10038221001
Policy instance	3
Insurance contract or identification number 10038221001 Number of Individuals Covered 89 Insurance policy start date 2018-01-01 Insurance policy end date 2018-12-31 Total amount of commissions paid to insurance broker USD $169 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $6,241 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $169 Insurance broker organization code? 3
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09069
Policy instance	2
Insurance contract or identification number 09069 Number of Individuals Covered 12226 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $3,622,845 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	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 258 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $53,280 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,768,384 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $53,280 Insurance broker organization code? 3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000021411
Policy instance	13
Insurance contract or identification number 0000021411 Number of Individuals Covered 12295 Insurance policy start date 2018-07-01 Insurance policy end date 2019-06-30 Total amount of commissions paid to insurance broker USD $1,121,614 Health Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,511,379 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $560,804 Insurance broker organization code? 3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980172
Policy instance	6
Insurance contract or identification number LK 980172 Number of Individuals Covered 1728 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $5,926 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $362,194 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	LK 100053
Policy instance	7
Insurance contract or identification number LK 100053 Number of Individuals Covered 1630 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $6,872 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $409,828 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	OK 980254
Policy instance	8
Insurance contract or identification number OK 980254 Number of Individuals Covered 12542 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $207 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $13,299 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	97674351001
Policy instance	17
Insurance contract or identification number 97674351001 Number of Individuals Covered 9766 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $16,816 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $612,977 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
JOHN HANCOCK LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93610 )
Policy contract number	60017
Policy instance	16
Insurance contract or identification number 60017 Number of Individuals Covered 57 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $13,545 Other welfare benefits provided GROUP LONG-TERM CARE Welfare Benefit Premiums Paid to Carrier USD $90,300 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
PRAM INSURANCE (National Association of Insurance Commissioners NAIC id number: 12747 )
Policy contract number	720119
Policy instance	15
Insurance contract or identification number 720119 Number of Individuals Covered 3224 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $85 Welfare Benefit Premiums Paid to Carrier USD $564 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	TDI980089
Policy instance	9
Insurance contract or identification number TDI980089 Number of Individuals Covered 765 Insurance policy start date 2017-02-01 Insurance policy end date 2018-01-31 Total amount of fees paid to insurance company USD $2,190 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $134,652 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	4055950010SSLS
Policy instance	14
Insurance contract or identification number 4055950010SSLS Number of Individuals Covered 4681 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Welfare Benefit Premiums Paid to Carrier USD $2,196,796 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000021411
Policy instance	13
Insurance contract or identification number 0000021411 Number of Individuals Covered 10134 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $1,149,026 Health Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $4,114,650 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266, 22570
Policy instance	11
Insurance contract or identification number 20266, 22570 Number of Individuals Covered 665 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,228,054 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074852
Policy instance	10
Insurance contract or identification number NYD074852 Number of Individuals Covered 824 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $788 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $55,831 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	FLX980233
Policy instance	5
Insurance contract or identification number FLX980233 Number of Individuals Covered 12542 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $1,150 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $77,660 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	FLX980238
Policy instance	4
Insurance contract or identification number FLX980238 Number of Individuals Covered 2055 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of fees paid to insurance company USD $10,455 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $673,608 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	10038221001
Policy instance	3
Insurance contract or identification number 10038221001 Number of Individuals Covered 97 Insurance policy start date 2017-01-01 Insurance policy end date 2017-12-31 Total amount of commissions paid to insurance broker USD $77 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,907 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09069
Policy instance	2
Insurance contract or identification number 09069 Number of Individuals Covered 11168 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,990,130 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	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 256 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $25,808 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,399,335 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	12
Insurance contract or identification number FV1238 Number of Individuals Covered 3224 Insurance policy start date 2017-07-01 Insurance policy end date 2018-06-30 Total amount of commissions paid to insurance broker USD $46,151 Total amount of fees paid to insurance company USD $383,805 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $923,023 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	22570
Policy instance	10
Insurance contract or identification number 22570 Number of Individuals Covered 36 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $263,888 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	TDI980089
Policy instance	9
Insurance contract or identification number TDI980089 Number of Individuals Covered 716 Insurance policy start date 2015-02-01 Insurance policy end date 2016-01-31 Total amount of fees paid to insurance company USD $1,710 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $127,690 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1710 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980254
Policy instance	8
Insurance contract or identification number OK 980254 Number of Individuals Covered 10435 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $154 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $10,472 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 154 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 100053
Policy instance	7
Insurance contract or identification number LK 100053 Number of Individuals Covered 1370 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $5,064 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $335,382 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 5064 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980172
Policy instance	6
Insurance contract or identification number LK 980172 Number of Individuals Covered 1316 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $3,828 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $266,595 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 3828 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980238
Policy instance	5
Insurance contract or identification number FLX980238 Number of Individuals Covered 1756 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $7,392 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $448,277 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 7392 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9767435
Policy instance	3
Insurance contract or identification number 9767435 Number of Individuals Covered 7919 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of commissions paid to insurance broker USD $13,802 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $455,038 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $13,802 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC 900
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	09069
Policy instance	2
Insurance contract or identification number 09069 Number of Individuals Covered 4848 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,611,563 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	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 188 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $26,828 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,307,968 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $26,828 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266
Policy instance	11
Insurance contract or identification number 20266 Number of Individuals Covered 194 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,276,967 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238
Policy instance	12
Insurance contract or identification number FV1238 Number of Individuals Covered 1668 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $28,095 Total amount of fees paid to insurance company USD $184,297 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $561,900 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $28,095 Amount paid for insurance broker fees 146666 Additional information about fees paid to insurance broker ADMINISTRATION Insurance broker organization code? 3 Insurance broker name FIRST HEALTH
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980233
Policy instance	4
Insurance contract or identification number FLX980233 Number of Individuals Covered 10435 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $978 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $66,637 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 978 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
JOHN HANCOCK LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93610 )
Policy contract number	60017
Policy instance	17
Insurance contract or identification number 60017 Number of Individuals Covered 67 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $3,435 Other welfare benefits provided GROUP LONG-TERM CARE Welfare Benefit Premiums Paid to Carrier USD $80,276 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $3,435 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract number	720119
Policy instance	16
Insurance contract or identification number 720119 Number of Individuals Covered 1668 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $516 Welfare Benefit Premiums Paid to Carrier USD $3,439 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $516 Insurance broker organization code? 3 Insurance broker name FRINGE INSURANCE BENEFITS, INC.
CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 )
Policy contract number	NYD074852
Policy instance	15
Insurance contract or identification number NYD074852 Number of Individuals Covered 633 Insurance policy start date 2015-01-01 Insurance policy end date 2015-12-31 Total amount of fees paid to insurance company USD $619 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $40,788 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 619 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000021411
Policy instance	13
Insurance contract or identification number 0000021411 Number of Individuals Covered 5736 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Total amount of commissions paid to insurance broker USD $1,291,879 Health Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,086,452 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $622,300 Insurance broker organization code? 3 Insurance broker name DARLENE S DILLON
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	4055950010SSLS
Policy instance	14
Insurance contract or identification number 4055950010SSLS Number of Individuals Covered 3854 Insurance policy start date 2015-07-01 Insurance policy end date 2016-06-30 Welfare Benefit Premiums Paid to Carrier USD $1,397,743 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	LK 100053
Policy instance	7
Insurance contract or identification number LK 100053 Number of Individuals Covered 1297 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $5,719 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $356,458 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 5719 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980172
Policy instance	6
Insurance contract or identification number LK 980172 Number of Individuals Covered 1229 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $4,437 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $270,722 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 4437 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980233
Policy instance	4
Insurance contract or identification number FLX980233 Number of Individuals Covered 9983 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $1,212 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $70,166 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1212 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNOR STRONG AND BUCKELEW
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 220 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $20,947 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,143,686 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $20,947 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980238
Policy instance	5
Insurance contract or identification number FLX980238 Number of Individuals Covered 1593 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $8,554 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $540,301 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 8554 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
DELTA DENTAL OF NJ INC (National Association of Insurance Commissioners NAIC id number: 55085 )
Policy contract number	9069
Policy instance	2
Insurance contract or identification number 9069 Number of Individuals Covered 4098 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $2,301,358 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9767435
Policy instance	3
Insurance contract or identification number 9767435 Number of Individuals Covered 7109 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of commissions paid to insurance broker USD $11,728 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $426,815 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $11,728 Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980254
Policy instance	8
Insurance contract or identification number OK 980254 Number of Individuals Covered 9983 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $190 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $11,026 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 190 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	TDI980089
Policy instance	9
Insurance contract or identification number TDI980089 Number of Individuals Covered 703 Insurance policy start date 2014-01-01 Insurance policy end date 2014-12-31 Total amount of fees paid to insurance company USD $1,942 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $109,830 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 1942 Insurance broker organization code? 3 Insurance broker name CONNER STRONG & BUCKELEW
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	22570
Policy instance	10
Insurance contract or identification number 22570 Number of Individuals Covered 40 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $232,697 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266
Policy instance	11
Insurance contract or identification number 20266 Number of Individuals Covered 151 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $983,279 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )
Policy contract number	FV1238, 720119
Policy instance	12
Insurance contract or identification number FV1238, 720119 Number of Individuals Covered 1521 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $17,157 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $306,096 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $17,157 Insurance broker organization code? 3 Insurance broker name FRINGE INSURANCE BENEFITS, INC.
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number	0000021411
Policy instance	13
Insurance contract or identification number 0000021411 Number of Individuals Covered 2939 Insurance policy start date 2014-07-01 Insurance policy end date 2015-06-30 Total amount of commissions paid to insurance broker USD $38,900 Health Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $63,498 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $19,450 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 100053
Policy instance	6
Insurance contract or identification number LK 100053 Number of Individuals Covered 1145 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of fees paid to insurance company USD $4,421 Temporary Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $283,873 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 4421 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK 980172
Policy instance	5
Insurance contract or identification number LK 980172 Number of Individuals Covered 1085 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of fees paid to insurance company USD $3,306 Long Term Disability Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $219,294 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 3306 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980238
Policy instance	4
Insurance contract or identification number FLX980238 Number of Individuals Covered 1711 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of fees paid to insurance company USD $8,057 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $461,081 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 8057 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	FLX980233
Policy instance	3
Insurance contract or identification number FLX980233 Number of Individuals Covered 9606 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of fees paid to insurance company USD $925 Life Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $60,015 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 925 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNOR STRONG AND BUCKELEW
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9767435
Policy instance	2
Insurance contract or identification number 9767435 Number of Individuals Covered 6944 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of commissions paid to insurance broker USD $12,940 Vision Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $374,664 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $12,940 Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number	6608
Policy instance	1
Insurance contract or identification number 6608 Number of Individuals Covered 232 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Total amount of commissions paid to insurance broker USD $4,164 Health Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $1,278,498 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Commission paid to Insurance Broker USD $4,164 Insurance broker organization code? 3 Insurance broker name LOCKTON COMPANIES, LLC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	OK 980254
Policy instance	7
Insurance contract or identification number OK 980254 Number of Individuals Covered 2174 Insurance policy start date 2013-01-01 Insurance policy end date 2013-12-31 Total amount of fees paid to insurance company USD $145 Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Welfare Benefit Premiums Paid to Carrier USD $9,431 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No Amount paid for insurance broker fees 145 Additional information about fees paid to insurance broker OVERRIDE Insurance broker organization code? 3 Insurance broker name CONNER STRONG AND BUCKELEW
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	TDI980089
Policy instance	8
Insurance contract or identification number TDI980089 Number of Individuals Covered 519 Insurance policy start date 2013-02-01 Insurance policy end date 2014-01-31 Other welfare benefits provided STATUTORY DISABILITY Welfare Benefit Premiums Paid to Carrier USD $96,159 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	22570
Policy instance	9
Insurance contract or identification number 22570 Number of Individuals Covered 39 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $217,882 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266
Policy instance	10
Insurance contract or identification number 20266 Number of Individuals Covered 166 Insurance policy start date 2013-07-01 Insurance policy end date 2014-06-30 Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Welfare Benefit Premiums Paid to Carrier USD $765,093 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	20266
Policy instance	1
Insurance contract or identification number 20266 Number of Individuals Covered 129 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $742,574 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	6608
Policy instance	4
Insurance contract or identification number 6608 Number of Individuals Covered 234 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $931,900 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	VARIOUS
Policy instance	3
Insurance contract or identification number VARIOUS Number of Individuals Covered 10742 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $922,799 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
HAWAII MEDICAL SERVICE ASSOC. (National Association of Insurance Commissioners NAIC id number: 49948 )
Policy contract number	22570
Policy instance	2
Insurance contract or identification number 22570 Number of Individuals Covered 28 Insurance policy start date 2012-07-01 Insurance policy end date 2013-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit Yes Dental Insurance Welfare Benefit Yes Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit No Temporary Disability Insurance Welfare Benefit No Long Term Disability Insurance Welfare Benefit No Unemployment Insurance Welfare Benefit No Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $79,195 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	VARIOUS
Policy instance	1
Insurance contract or identification number VARIOUS Number of Individuals Covered 7818 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 $23,835 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $741,599 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 62146 )
Policy contract number	9767435
Policy instance	2
Insurance contract or identification number 9767435 Number of Individuals Covered 2918 Insurance policy start date 2010-07-01 Insurance policy end date 2011-06-30 Total amount of commissions paid to insurance broker USD $4,228 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 $152,006 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number	800399
Policy instance	1
Insurance contract or identification number 800399 Number of Individuals Covered 226 Insurance policy start date 2010-07-01 Insurance policy end date 2011-06-30 Total amount of commissions paid to insurance broker USD $0 Total amount of fees paid to insurance company USD $0 Are there contracts with allocated funds for individual policies? No Are there contracts with allocated funds for group deferred annuity? No Are there contracts with allocated funds for types other than group deferred annuity or individual? No Contract purchased, in whole or in part, to distribute benefits from a terminating plan No Contracts With Unallocated Funds Deposit Administration 0 Are there contracts with unallocated funds for contracts of type immediate participation guarantee? No Are there contracts with unallocated funds for contracts of type guaranteed investment? No Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? No Health Insurance Welfare Benefit 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 $421,253 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	37544
Policy instance	3
Insurance contract or identification number 37544 Number of Individuals Covered 10124 Insurance policy start date 2010-07-01 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 No Dental Insurance Welfare Benefit No Vision Insurance Welfare Benefit No Life Insurance Welfare Benefit Yes Temporary Disability Insurance Welfare Benefit Yes Long Term Disability Insurance Welfare Benefit Yes Unemployment Insurance Welfare Benefit No Other welfare benefits provided ACCIDENTAL DEATH AND DISMEMBERMENT Were dividends or retroactive rate refunds paid in cash? No Were dividends or retroactive rate refunds paid as a credit? No Welfare Benefit Premiums Paid to Carrier USD $431,227 Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? No