CENTRIA HEALTHCARE LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CENTRIA HEALTHCARE HEALTH AND WELFARE PLAN
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 605446 |
| Policy instance | 1 |
| Insurance contract or identification number | 605446 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $3,810 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $93,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,810 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00034054 |
| Policy instance | 4 |
| Insurance contract or identification number | 00034054 | | Number of Individuals Covered | 961 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $56,976 | | Total amount of fees paid to insurance company | USD $14,086 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, ACCIDENT, HOSPITAL INDEMNITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $581,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,031 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514S001 |
| Policy instance | 3 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 735 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $118,715 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,957,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $118,220 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514S001 |
| Policy instance | 2 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $46,988 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,791,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,736 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5232442 |
| Policy instance | 5 |
| Insurance contract or identification number | E5232442 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $75,391 | | Total amount of fees paid to insurance company | USD $368 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $258,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,393 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514S001 |
| Policy instance | 6 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 520 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $77,847 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,594,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,273 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233407 |
| Policy instance | 4 |
| Insurance contract or identification number | 233407 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $18,938 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $366,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,938 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5936538 |
| Policy instance | 2 |
| Insurance contract or identification number | 5936538 | | Number of Individuals Covered | 837 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $17,197 | | Total amount of fees paid to insurance company | USD $1,090 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $139,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,891 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5232442 |
| Policy instance | 7 |
| Insurance contract or identification number | E5232442 | | Number of Individuals Covered | 450 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $91,196 | | Total amount of fees paid to insurance company | USD $1,953 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $367,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,221 | | Amount paid for insurance broker fees | 995 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 4490 |
| Policy instance | 1 |
| Insurance contract or identification number | 4490 | | Number of Individuals Covered | 1231 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $10,241 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,410 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514S001 |
| Policy instance | 5 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $46,443 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,548,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,522 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30090302 |
| Policy instance | 3 |
| Insurance contract or identification number | 30090302 | | Number of Individuals Covered | 692 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $2,661 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,084 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4603122 |
| Policy instance | 8 |
| Insurance contract or identification number | E4603122 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $3,174 | | Total amount of fees paid to insurance company | USD $4 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $46,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $585 | | Amount paid for insurance broker fees | 2 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514S001 |
| Policy instance | 8 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 1303 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $64,783 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,953,719 | | Commission paid to Insurance Broker | USD $64,783 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4603122 |
| Policy instance | 7 |
| Insurance contract or identification number | E4603122 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $7,100 | | Total amount of fees paid to insurance company | USD $101 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $79,311 | | Commission paid to Insurance Broker | USD $964 | | Amount paid for insurance broker fees | 13 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 4490 |
| Policy instance | 1 |
| Insurance contract or identification number | 4490 | | Number of Individuals Covered | 1329 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $12,276 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Commission paid to Insurance Broker | USD $12,276 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5936538 |
| Policy instance | 2 |
| Insurance contract or identification number | 5936538 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $8,897 | | Total amount of fees paid to insurance company | USD $373 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $26,268 | | Commission paid to Insurance Broker | USD $5,912 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30090302 |
| Policy instance | 3 |
| Insurance contract or identification number | 30090302 | | Number of Individuals Covered | 744 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $2,480 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Commission paid to Insurance Broker | USD $2,480 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233407 |
| Policy instance | 4 |
| Insurance contract or identification number | 233407 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $15,480 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $330,043 | | Commission paid to Insurance Broker | USD $15,480 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5232442 |
| Policy instance | 6 |
| Insurance contract or identification number | E5232442 | | Number of Individuals Covered | 540 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $98,994 | | Total amount of fees paid to insurance company | USD $12,235 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $421,672 | | Commission paid to Insurance Broker | USD $5,978 | | Amount paid for insurance broker fees | 454 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 605446 |
| Policy instance | 5 |
| Insurance contract or identification number | 605446 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $3,835 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $85,456 | | Commission paid to Insurance Broker | USD $61 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514S001 |
| Policy instance | 9 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 505 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $84,908 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,695,383 | | Commission paid to Insurance Broker | USD $84,908 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4603122 |
| Policy instance | 1 |
| Insurance contract or identification number | E4603122 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $50,435 | | Total amount of fees paid to insurance company | USD $3,412 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $158,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,435 | | Amount paid for insurance broker fees | 3412 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5232442 |
| Policy instance | 2 |
| Insurance contract or identification number | E5232442 | | Number of Individuals Covered | 658 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $168,404 | | Total amount of fees paid to insurance company | USD $13,072 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $500,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $168,404 | | Amount paid for insurance broker fees | 13072 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 4490 |
| Policy instance | 3 |
| Insurance contract or identification number | 4490 | | Number of Individuals Covered | 1467 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $15,281 | | Total amount of fees paid to insurance company | USD $1,245 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,424 | | Amount paid for insurance broker fees | 1245 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233407 |
| Policy instance | 4 |
| Insurance contract or identification number | 233407 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $15,663 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $291,357 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,446 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5936538 |
| Policy instance | 6 |
| Insurance contract or identification number | 5936538 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $10,786 | | Total amount of fees paid to insurance company | USD $1,041 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,049 | | Amount paid for insurance broker fees | 73 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514S001 |
| Policy instance | 7 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 1741 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $69,045 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,155,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,982 | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514S001 |
| Policy instance | 8 |
| Insurance contract or identification number | 790514S001 | | Number of Individuals Covered | 614 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $76,789 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,681,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,534 | | Insurance broker organization code? | 3 |
|
| ULLIANCE, INC. (National Association of Insurance Commissioners NAIC id number: 62419 ) |
| Policy contract number | NONE |
| Policy instance | 9 |
| Insurance contract or identification number | NONE | | Number of Individuals Covered | 747 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PLAN | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30090302 |
| Policy instance | 10 |
| Insurance contract or identification number | 30090302 | | Number of Individuals Covered | 825 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,093 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,093 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 605446 |
| Policy instance | 5 |
| Insurance contract or identification number | 605446 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $4,585 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $81,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,131 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5232442 |
| Policy instance | 2 |
| Insurance contract or identification number | E5232442 | | Number of Individuals Covered | 474 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $10,841 | | Total amount of fees paid to insurance company | USD $2,071 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $16,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,783 | | Amount paid for insurance broker fees | 1151 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514-S001 |
| Policy instance | 1 |
| Insurance contract or identification number | 790514-S001 | | Number of Individuals Covered | 474 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $61,604 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,053,477 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,604 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4603122 |
| Policy instance | 3 |
| Insurance contract or identification number | E4603122 | | Number of Individuals Covered | 411 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $273,758 | | Total amount of fees paid to insurance company | USD $47,965 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $541,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98,423 | | Amount paid for insurance broker fees | 2332 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5936538 |
| Policy instance | 4 |
| Insurance contract or identification number | 5936538 | | Number of Individuals Covered | 1569 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $17,361 | | Total amount of fees paid to insurance company | USD $1,734 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $121,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,488 | | Amount paid for insurance broker fees | 75 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 4490 |
| Policy instance | 5 |
| Insurance contract or identification number | 4490 | | Number of Individuals Covered | 1366 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $25,581 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,236 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514-S001 |
| Policy instance | 6 |
| Insurance contract or identification number | 790514-S001 | | Number of Individuals Covered | 635 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $84,257 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,802,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,257 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 233407 |
| Policy instance | 7 |
| Insurance contract or identification number | 233407 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $13,893 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $281,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,893 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 605446 |
| Policy instance | 6 |
| Insurance contract or identification number | 605446 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $4,619 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $104,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,619 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 790514 |
| Policy instance | 1 |
| Insurance contract or identification number | 790514 | | Number of Individuals Covered | 569 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $59,534 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,951,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,534 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHAEL GREEN |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4603122 |
| Policy instance | 5 |
| Insurance contract or identification number | E4603122 | | Number of Individuals Covered | 451 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $211,790 | | Total amount of fees paid to insurance company | USD $13,464 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $404,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78,236 | | Amount paid for insurance broker fees | 2771 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | THAD ANDERSON |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 790514 |
| Policy instance | 4 |
| Insurance contract or identification number | 790514 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $19,390 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $641,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,390 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHAEL GREEN |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 4490 |
| Policy instance | 3 |
| Insurance contract or identification number | 4490 | | Number of Individuals Covered | 939 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $18,163 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $18,163 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05936538 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05936538 | | Number of Individuals Covered | 899 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $6,137 | | Total amount of fees paid to insurance company | USD $772 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,721 | | Amount paid for insurance broker fees | 64 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES, INC. |
|
