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EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan NameEMERALD TEXTILES, LLC WELFARE BENEFITS PLAN
Plan identification number 501

EMERALD TEXTILES, LLC WELFARE BENEFITS 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

EMERALD TEXTILES, SAN DIEGO, LLC has sponsored the creation of one or more 401k plans.

Company Name:EMERALD TEXTILES, SAN DIEGO, LLC
Employer identification number (EIN):271167089
NAIC Classification:812330
NAIC Description: Linen and Uniform Supply

Additional information about EMERALD TEXTILES, SAN DIEGO, LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 200928810157

More information about EMERALD TEXTILES, SAN DIEGO, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01STEVEN A. BEACH2023-07-06
5012021-01-01VICTOR MORAN2022-10-17
5012020-01-01
5012019-01-01
5012018-12-01VICTOR MORAN2019-08-01
5012017-12-01VICTOR MORAN2019-08-01
5012016-12-01VICTOR MORAN VICTOR MORAN2018-09-12
5012015-12-01BROOK LOGAN BROOK LOGAN2017-09-15
5012014-12-01BROOK LOGAN
5012013-12-01BROOK LOGAN
5012012-12-01BROOK LOGAN
5012011-12-01BROOK LOGAN

Plan Statistics for EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN

Measure Date Value
2022: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-012,100
Total number of active participants reported on line 7a of the Form 55002022-01-012,100
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-012,100
Number of employers contributing to the scheme2022-01-010
2021: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-011,100
Total number of active participants reported on line 7a of the Form 55002021-01-012,100
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-012,100
Number of employers contributing to the scheme2021-01-010
2020: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01770
Total number of active participants reported on line 7a of the Form 55002020-01-01190
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01190
2019: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01295
Total number of active participants reported on line 7a of the Form 55002019-01-01770
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01770
2018: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-12-01299
Total number of active participants reported on line 7a of the Form 55002018-12-01293
Number of retired or separated participants receiving benefits2018-12-012
Number of other retired or separated participants entitled to future benefits2018-12-010
Total of all active and inactive participants2018-12-01295
Number of employers contributing to the scheme2018-12-010
2017: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-12-01282
Total number of active participants reported on line 7a of the Form 55002017-12-01297
Number of retired or separated participants receiving benefits2017-12-012
Number of other retired or separated participants entitled to future benefits2017-12-010
Total of all active and inactive participants2017-12-01299
Number of employers contributing to the scheme2017-12-010
2016: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-12-01289
Total number of active participants reported on line 7a of the Form 55002016-12-01282
Number of retired or separated participants receiving benefits2016-12-010
Number of other retired or separated participants entitled to future benefits2016-12-010
Total of all active and inactive participants2016-12-01282
2015: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-12-01261
Total number of active participants reported on line 7a of the Form 55002015-12-01289
Number of retired or separated participants receiving benefits2015-12-010
Number of other retired or separated participants entitled to future benefits2015-12-010
Total of all active and inactive participants2015-12-01289
2014: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-12-01189
Total number of active participants reported on line 7a of the Form 55002014-12-01260
Number of retired or separated participants receiving benefits2014-12-011
Number of other retired or separated participants entitled to future benefits2014-12-010
Total of all active and inactive participants2014-12-01261
2013: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-12-01186
Total number of active participants reported on line 7a of the Form 55002013-12-01189
Number of retired or separated participants receiving benefits2013-12-010
Number of other retired or separated participants entitled to future benefits2013-12-010
Total of all active and inactive participants2013-12-01189
2012: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-12-01162
Total number of active participants reported on line 7a of the Form 55002012-12-01185
Number of retired or separated participants receiving benefits2012-12-011
Number of other retired or separated participants entitled to future benefits2012-12-010
Total of all active and inactive participants2012-12-01186
2011: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-12-01131
Total number of active participants reported on line 7a of the Form 55002011-12-01161
Number of retired or separated participants receiving benefits2011-12-011
Number of other retired or separated participants entitled to future benefits2011-12-010
Total of all active and inactive participants2011-12-01162

Form 5500 Responses for EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN

2022: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-12-01Type of plan entitySingle employer plan
2018-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-12-01Plan funding arrangement – InsuranceYes
2018-12-01Plan funding arrangement – General assets of the sponsorYes
2018-12-01Plan benefit arrangement – InsuranceYes
2018-12-01Plan benefit arrangement – General assets of the sponsorYes
2017: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-12-01Type of plan entitySingle employer plan
2017-12-01Plan funding arrangement – InsuranceYes
2017-12-01Plan funding arrangement – General assets of the sponsorYes
2017-12-01Plan benefit arrangement – InsuranceYes
2017-12-01Plan benefit arrangement – General assets of the sponsorYes
2016: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-12-01Type of plan entitySingle employer plan
2016-12-01Submission has been amendedNo
2016-12-01This submission is the final filingNo
2016-12-01This return/report is a short plan year return/report (less than 12 months)No
2016-12-01Plan is a collectively bargained planNo
2016-12-01Plan funding arrangement – General assets of the sponsorYes
2016-12-01Plan benefit arrangement – InsuranceYes
2016-12-01Plan benefit arrangement – General assets of the sponsorYes
2015: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-12-01Type of plan entitySingle employer plan
2015-12-01Submission has been amendedNo
2015-12-01This submission is the final filingNo
2015-12-01This return/report is a short plan year return/report (less than 12 months)No
2015-12-01Plan is a collectively bargained planNo
2015-12-01Plan funding arrangement – General assets of the sponsorYes
2015-12-01Plan benefit arrangement – InsuranceYes
2015-12-01Plan benefit arrangement – General assets of the sponsorYes
2014: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-12-01Type of plan entitySingle employer plan
2014-12-01Submission has been amendedNo
2014-12-01This submission is the final filingNo
2014-12-01This return/report is a short plan year return/report (less than 12 months)No
2014-12-01Plan is a collectively bargained planNo
2014-12-01Plan funding arrangement – General assets of the sponsorYes
2014-12-01Plan benefit arrangement – InsuranceYes
2014-12-01Plan benefit arrangement – General assets of the sponsorYes
2013: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-12-01Type of plan entitySingle employer plan
2013-12-01Submission has been amendedNo
2013-12-01This submission is the final filingNo
2013-12-01This return/report is a short plan year return/report (less than 12 months)No
2013-12-01Plan is a collectively bargained planNo
2013-12-01Plan funding arrangement – General assets of the sponsorYes
2013-12-01Plan benefit arrangement – InsuranceYes
2013-12-01Plan benefit arrangement – General assets of the sponsorYes
2012: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-12-01Type of plan entitySingle employer plan
2012-12-01Submission has been amendedNo
2012-12-01This submission is the final filingNo
2012-12-01This return/report is a short plan year return/report (less than 12 months)No
2012-12-01Plan is a collectively bargained planNo
2012-12-01Plan funding arrangement – General assets of the sponsorYes
2012-12-01Plan benefit arrangement – InsuranceYes
2012-12-01Plan benefit arrangement – General assets of the sponsorYes
2011: EMERALD TEXTILES, LLC WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-12-01Type of plan entitySingle employer plan
2011-12-01First time form 5500 has been submittedYes
2011-12-01Submission has been amendedNo
2011-12-01This submission is the final filingNo
2011-12-01This return/report is a short plan year return/report (less than 12 months)No
2011-12-01Plan is a collectively bargained planNo
2011-12-01Plan funding arrangement – General assets of the sponsorYes
2011-12-01Plan benefit arrangement – InsuranceYes
2011-12-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5974935
Policy instance 7
Insurance contract or identification number5974935
Number of Individuals Covered2107
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $133,782
Total amount of fees paid to insurance companyUSD $8,674
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS,ACCIDENT,HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $935,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76,662
Amount paid for insurance broker fees180
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )
Policy contract number5974935
Policy instance 6
Insurance contract or identification number5974935
Number of Individuals Covered241
Insurance policy start date2022-01-01
Insurance policy end date2022-12-01
Total amount of commissions paid to insurance brokerUSD $2,580
Total amount of fees paid to insurance companyUSD $443
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,580
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number181685HNO
Policy instance 5
Insurance contract or identification number181685HNO
Number of Individuals Covered575
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $162,662
Total amount of fees paid to insurance companyUSD $20,000
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,756,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $162,662
Amount paid for insurance broker fees20000
Additional information about fees paid to insurance broker2022 Q1 NEW BUSINESS INCENTIVE RISK
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number181685
Policy instance 4
Insurance contract or identification number181685
Number of Individuals Covered350
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $113,811
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,637,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $113,811
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )
Policy contract number10921B/10921F
Policy instance 3
Insurance contract or identification number10921B/10921F
Number of Individuals Covered26
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,062
Total amount of fees paid to insurance companyUSD $3,212
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,729
Amount paid for insurance broker fees3212
Additional information about fees paid to insurance brokerINDIRECT COMPENSATION
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number641
Policy instance 2
Insurance contract or identification number641
Number of Individuals Covered297
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $60,238
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $860,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $60,238
Amount paid for insurance broker fees0
Insurance broker organization code?3
MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 )
Policy contract numberA726
Policy instance 1
Insurance contract or identification numberA726
Number of Individuals Covered208
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,474
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,474
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number98062901001
Policy instance 1
Insurance contract or identification number98062901001
Number of Individuals Covered2100
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 )
Policy contract numberA726
Policy instance 2
Insurance contract or identification numberA726
Number of Individuals Covered226
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,453
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,453
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number365387
Policy instance 3
Insurance contract or identification number365387
Number of Individuals Covered2100
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number641
Policy instance 4
Insurance contract or identification number641
Number of Individuals Covered564
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $57,353
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $819,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $57,353
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )
Policy contract number10921
Policy instance 5
Insurance contract or identification number10921
Number of Individuals Covered43
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,592
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,319
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $654
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BPGV
Policy instance 5
Insurance contract or identification numberGLTD0BPGV
Number of Individuals Covered929
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $11,382
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 BenefitYes
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 $113,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,886
Insurance broker organization code?3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number1006386
Policy instance 6
Insurance contract or identification number1006386
Number of Individuals Covered306
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $49,372
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 $1,097,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,372
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605456
Policy instance 7
Insurance contract or identification number605456
Number of Individuals Covered162
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $50,123
Total amount of fees paid to insurance companyUSD $1
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $1,012,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,570
Insurance broker organization code?3
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUVC0BPGV
Policy instance 8
Insurance contract or identification numberGUVC0BPGV
Number of Individuals Covered362
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,445
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 BenefitYes
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 $54,449
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,135
Insurance broker organization code?3
NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )
Policy contract numberTC226
Policy instance 9
Insurance contract or identification numberTC226
Number of Individuals Covered9
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,148
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 $158,847
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,148
Insurance broker organization code?3
CALIFORNIA DENTAL NETWORK, INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number003751 ET AL
Policy instance 10
Insurance contract or identification number003751 ET AL
Number of Individuals Covered186
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,465
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 BenefitYes
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 $54,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,906
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDS0BPGV
Policy instance 11
Insurance contract or identification numberGUDS0BPGV
Number of Individuals Covered147
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,262
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 BenefitYes
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 $90,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,556
Insurance broker organization code?3
MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 )
Policy contract numberA726
Policy instance 4
Insurance contract or identification numberA726
Number of Individuals Covered213
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,323
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 $14,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,323
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BPGV
Policy instance 3
Insurance contract or identification numberGVTL0BPGV
Number of Individuals Covered188
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,981
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 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 $39,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,315
Insurance broker organization code?3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number641/9641
Policy instance 2
Insurance contract or identification number641/9641
Number of Individuals Covered580
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $56,870
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 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 $812,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $56,870
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BPGV
Policy instance 1
Insurance contract or identification numberGLUG0BPGV
Number of Individuals Covered932
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,093
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 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 $40,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,481
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98062901001
Policy instance 8
Insurance contract or identification number98062901001
Number of Individuals Covered509
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,682
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 BenefitYes
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 $29,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,714
Insurance broker organization code?3
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number641/9641
Policy instance 7
Insurance contract or identification number641/9641
Number of Individuals Covered603
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $58,134
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 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 $834,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,830
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number225615
Policy instance 6
Insurance contract or identification number225615
Number of Individuals Covered262
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,992
Total amount of fees paid to insurance companyUSD $1,400
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 BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D AND EAP
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,992
Amount paid for insurance broker fees1400
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number1006386
Policy instance 5
Insurance contract or identification number1006386
Number of Individuals Covered233
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $49,643
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 $1,103,167
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,643
Insurance broker organization code?3
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number899930-000
Policy instance 4
Insurance contract or identification number899930-000
Number of Individuals Covered16
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,861
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 BenefitYes
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 $17,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,120
Insurance broker organization code?3
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number899930-001
Policy instance 3
Insurance contract or identification number899930-001
Number of Individuals Covered151
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,339
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 BenefitYes
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 $49,357
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,291
Insurance broker organization code?3
MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 )
Policy contract numberA726
Policy instance 2
Insurance contract or identification numberA726
Number of Individuals Covered196
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,541
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 $13,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,094
Insurance broker organization code?3
NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )
Policy contract numberTC226
Policy instance 9
Insurance contract or identification numberTC226
Number of Individuals Covered6
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,063
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 $134,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,063
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number605456
Policy instance 1
Insurance contract or identification number605456
Number of Individuals Covered116
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $28,684
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 $610,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,470
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number98062901001
Policy instance 1
Insurance contract or identification number98062901001
Number of Individuals Covered522
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $3,922
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $31,339
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SHARP HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number1006386
Policy instance 3
Insurance contract or identification number1006386
Number of Individuals Covered235
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $51,540
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,145,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number225615
Policy instance 4
Insurance contract or identification number225615
Number of Individuals Covered284
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $5,479
Total amount of fees paid to insurance companyUSD $1,211
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $55,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number899930-001
Policy instance 5
Insurance contract or identification number899930-001
Number of Individuals Covered396
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $10,342
Total amount of fees paid to insurance companyUSD $44
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $52,113
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number899930-000
Policy instance 6
Insurance contract or identification number899930-000
Number of Individuals Covered47
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $3,788
Total amount of fees paid to insurance companyUSD $16
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SIMNSA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number641
Policy instance 7
Insurance contract or identification number641
Number of Individuals Covered544
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $51,744
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $739,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
NATIONAL HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 82538 )
Policy contract numberTC226
Policy instance 8
Insurance contract or identification numberTC226
Number of Individuals Covered297
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $6,702
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $148,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MEDIEXCEL HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 15347 )
Policy contract numberA726
Policy instance 2
Insurance contract or identification numberA726
Number of Individuals Covered185
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $3,717
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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