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SAVE THE QUEEN HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameSAVE THE QUEEN HEALTH AND WELFARE PLAN
Plan identification number 501

SAVE THE QUEEN HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

URBAN COMMONS QUEENSWAY, LLC has sponsored the creation of one or more 401k plans.

Company Name:URBAN COMMONS QUEENSWAY, LLC
Employer identification number (EIN):260648863
NAIC Classification:721110
NAIC Description:Hotels (except Casino Hotels) and Motels

Additional information about URBAN COMMONS QUEENSWAY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 4362295

More information about URBAN COMMONS QUEENSWAY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SAVE THE QUEEN HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-06-01
5012019-06-01
5012018-06-01
5012018-06-01
5012017-11-01JESSICA SCHMIDT
5012016-11-01JESSICA SCHMIDT
5012015-11-01JESSICA SCHMIDT
5012014-11-01DARCY M LEHMUTH
5012013-11-01DARCY LEHMUTH DARCY LEHMUTH2015-04-22
5012012-11-01DARCY LEHMUTH DARCY LEHMUTH2014-04-24
5012011-11-01DARCY LEHMUTH DARCY LEHMUTH2014-06-23
5012008-11-01JACK SCIBONA

Plan Statistics for SAVE THE QUEEN HEALTH AND WELFARE PLAN

401k plan membership statisitcs for SAVE THE QUEEN HEALTH AND WELFARE PLAN

Measure Date Value
2020: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01276
Total number of active participants reported on line 7a of the Form 55002020-06-01300
Number of retired or separated participants receiving benefits2020-06-010
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01300
2019: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01329
Total number of active participants reported on line 7a of the Form 55002019-06-01276
Number of retired or separated participants receiving benefits2019-06-010
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01276
2018: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01283
Total number of active participants reported on line 7a of the Form 55002018-06-01329
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01329
2017: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01272
Total number of active participants reported on line 7a of the Form 55002017-11-01283
Number of retired or separated participants receiving benefits2017-11-010
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01283
2016: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01275
Total number of active participants reported on line 7a of the Form 55002016-11-01272
Number of retired or separated participants receiving benefits2016-11-010
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01272
2015: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01173
Total number of active participants reported on line 7a of the Form 55002015-11-01275
Number of retired or separated participants receiving benefits2015-11-010
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01275
2014: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01173
Total number of active participants reported on line 7a of the Form 55002014-11-01195
Number of retired or separated participants receiving benefits2014-11-010
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01195
2013: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-11-01163
Total number of active participants reported on line 7a of the Form 55002013-11-01173
Number of retired or separated participants receiving benefits2013-11-010
Number of other retired or separated participants entitled to future benefits2013-11-010
Total of all active and inactive participants2013-11-01173
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-11-010
Total participants2013-11-01173
Number of participants with account balances2013-11-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2013-11-010
2012: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-11-01168
Total number of active participants reported on line 7a of the Form 55002012-11-01163
Number of retired or separated participants receiving benefits2012-11-010
Number of other retired or separated participants entitled to future benefits2012-11-010
Total of all active and inactive participants2012-11-01163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-11-010
Total participants2012-11-01163
Number of participants with account balances2012-11-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2012-11-010
2011: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01167
Total number of active participants reported on line 7a of the Form 55002011-11-01125
Number of retired or separated participants receiving benefits2011-11-010
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01125
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2011-11-010
Total participants2011-11-01125
Number of participants with account balances2011-11-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2011-11-010
2008: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year2008-11-01140
Total number of active participants reported on line 7a of the Form 55002008-11-010
Number of retired or separated participants receiving benefits2008-11-010
Number of other retired or separated participants entitled to future benefits2008-11-01161
Total of all active and inactive participants2008-11-01161
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2008-11-010
Total participants2008-11-01161
Number of participants with account balances2008-11-010
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2008-11-010

Form 5500 Responses for SAVE THE QUEEN HEALTH AND WELFARE PLAN

2020: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Submission has been amendedNo
2020-06-01This submission is the final filingNo
2020-06-01This return/report is a short plan year return/report (less than 12 months)Yes
2020-06-01Plan is a collectively bargained planNo
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – InsuranceYes
2019: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedNo
2019-06-01This submission is the final filingNo
2019-06-01This return/report is a short plan year return/report (less than 12 months)No
2019-06-01Plan is a collectively bargained planNo
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – InsuranceYes
2018: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedYes
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – InsuranceYes
2017: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – InsuranceYes
2016: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – InsuranceYes
2015: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – InsuranceYes
2014: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01Submission has been amendedNo
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – InsuranceYes
2013: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-11-01Type of plan entitySingle employer plan
2013-11-01Submission has been amendedNo
2013-11-01This submission is the final filingNo
2013-11-01This return/report is a short plan year return/report (less than 12 months)No
2013-11-01Plan is a collectively bargained planNo
2013-11-01Plan funding arrangement – InsuranceYes
2013-11-01Plan benefit arrangement – InsuranceYes
2012: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-11-01Type of plan entitySingle employer plan
2012-11-01Submission has been amendedNo
2012-11-01This submission is the final filingNo
2012-11-01This return/report is a short plan year return/report (less than 12 months)No
2012-11-01Plan is a collectively bargained planNo
2012-11-01Plan funding arrangement – InsuranceYes
2012-11-01Plan benefit arrangement – InsuranceYes
2011: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedYes
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)No
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – InsuranceYes
2008: SAVE THE QUEEN HEALTH AND WELFARE PLAN 2008 form 5500 responses
2008-11-01Type of plan entitySingle employer plan
2008-11-01First time form 5500 has been submittedYes
2008-11-01Submission has been amendedNo
2008-11-01This submission is the final filingNo
2008-11-01This return/report is a short plan year return/report (less than 12 months)No
2008-11-01Plan is a collectively bargained planNo
2008-11-01Plan funding arrangement – InsuranceYes
2008-11-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233351
Policy instance 1
Insurance contract or identification number233351
Number of Individuals Covered0
Insurance policy start date2020-06-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $13,477
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $186,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,477
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number804758G
Policy instance 4
Insurance contract or identification number804758G
Number of Individuals Covered300
Insurance policy start date2019-11-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $606
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD AND VOLUNTARY LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $606
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0759945HNO
Policy instance 3
Insurance contract or identification number0759945HNO
Number of Individuals Covered3
Insurance policy start date2020-06-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $607
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $607
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0759945
Policy instance 2
Insurance contract or identification number0759945
Number of Individuals Covered5
Insurance policy start date2020-06-01
Insurance policy end date2020-08-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0759945
Policy instance 2
Insurance contract or identification number0759945
Number of Individuals Covered276
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $12,086
Total amount of fees paid to insurance companyUSD $4,710
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $125,368
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,086
Amount paid for insurance broker fees4710
Additional information about fees paid to insurance brokerPREMIERE PRODUCER PROGRAM
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233351
Policy instance 1
Insurance contract or identification number233351
Number of Individuals Covered1642727
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $29,273
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $600,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,273
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0759945HNO
Policy instance 3
Insurance contract or identification number0759945HNO
Number of Individuals Covered146
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $43,301
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $614,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,301
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0759945HNO
Policy instance 3
Insurance contract or identification number0759945HNO
Number of Individuals Covered155
Insurance policy start date2018-11-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $51,060
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $905,324
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,060
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0759945
Policy instance 2
Insurance contract or identification number0759945
Number of Individuals Covered329
Insurance policy start date2018-11-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $13,674
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $171,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,674
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233351
Policy instance 1
Insurance contract or identification number995807-000
Number of Individuals Covered0
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,519
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?Yes
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $1,519
Insurance broker organization code?3
Welfare Benefit Premiums Paid to CarrierUSD $920,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees82
Additional information about fees paid to insurance brokerBONUS
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number0759945HNO
Policy instance 3
Insurance contract or identification number0759945HNO
Number of Individuals Covered186
Insurance policy start date2017-11-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $26,432
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $545,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,347
Insurance broker organization code?3
Insurance broker nameWORD & BROWN INS ADMIN INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0759945
Policy instance 2
Insurance contract or identification number0759945
Number of Individuals Covered283
Insurance policy start date2017-11-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $7,170
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $96,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,925
Insurance broker organization code?3
Insurance broker nameWORD & BROWN INSURANCE
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number233351
Policy instance 1
Insurance contract or identification number233351
Number of Individuals Covered121
Insurance policy start date2017-11-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $17,750
Total amount of fees paid to insurance companyUSD $2,489
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $334,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,583
Amount paid for insurance broker fees2489
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameALLIANT INSURANCE SERVICES INC.

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