UNION SUPPLY GROUP, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan UNION SUPPLY COMPANY WELFARE BENEFITS PLAN
| 2022: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Submission has been amended | No |
| 2020-04-01 | This submission is the final filing | No |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-04-01 | Plan is a collectively bargained plan | No |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Submission has been amended | No |
| 2019-04-01 | This submission is the final filing | No |
| 2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-04-01 | Plan is a collectively bargained plan | No |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Submission has been amended | Yes |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Submission has been amended | No |
| 2016-04-01 | This submission is the final filing | No |
| 2016-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-04-01 | Plan is a collectively bargained plan | No |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Submission has been amended | No |
| 2015-04-01 | This submission is the final filing | No |
| 2015-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-04-01 | Plan is a collectively bargained plan | No |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Submission has been amended | No |
| 2013-04-01 | This submission is the final filing | No |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-04-01 | Plan is a collectively bargained plan | No |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Submission has been amended | No |
| 2012-04-01 | This submission is the final filing | No |
| 2012-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-04-01 | Plan is a collectively bargained plan | No |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Submission has been amended | No |
| 2011-04-01 | This submission is the final filing | No |
| 2011-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-04-01 | Plan is a collectively bargained plan | No |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | First time form 5500 has been submitted | Yes |
| 2010-04-01 | Submission has been amended | No |
| 2010-04-01 | This submission is the final filing | No |
| 2010-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-04-01 | Plan is a collectively bargained plan | No |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | First time form 5500 has been submitted | Yes |
| 2009-04-01 | Submission has been amended | No |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-04-01 | Plan is a collectively bargained plan | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: UNION SUPPLY COMPANY WELFARE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-04-01 | Type of plan entity | Single employer plan |
| 2008-04-01 | First time form 5500 has been submitted | Yes |
| 2008-04-01 | Submission has been amended | No |
| 2008-04-01 | This submission is the final filing | No |
| 2008-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-04-01 | Plan is a collectively bargained plan | No |
| 2008-04-01 | Plan funding arrangement – Insurance | Yes |
| 2008-04-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BBX3 |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0BBX3 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $4,842 | | Total amount of fees paid to insurance company | USD $1,290 | | 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 & 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 $32,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,842 | | Amount paid for insurance broker fees | 1290 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 282920 |
| Policy instance | 1 |
| Insurance contract or identification number | 282920 | | Number of Individuals Covered | 695 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $115,876 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 | 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 $196,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $115,876 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | G0200 |
| Policy instance | 2 |
| Insurance contract or identification number | G0200 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 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 $2,088,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BBX3 |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0BBX3 | | Number of Individuals Covered | 438 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $1,695 | | Total amount of fees paid to insurance company | USD $653 | | 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 & 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 $16,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,695 | | Amount paid for insurance broker fees | 653 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BBX3 |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0BBX3 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $505 | | Total amount of fees paid to insurance company | USD $199 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,049 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $505 | | Amount paid for insurance broker fees | 199 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BBX3 |
| Policy instance | 5 |
| Insurance contract or identification number | GUG0BBX3 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $724 | | Total amount of fees paid to insurance company | USD $281 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $724 | | Amount paid for insurance broker fees | 281 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBX3 |
| Policy instance | 6 |
| Insurance contract or identification number | GUC0BBX3 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $4,652 | | Total amount of fees paid to insurance company | USD $1,798 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $46,520 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,652 | | Amount paid for insurance broker fees | 1798 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 282920 |
| Policy instance | 1 |
| Insurance contract or identification number | 282920 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $116,888 | | Total amount of fees paid to insurance company | USD $13,574 | | 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 | Yes | | 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 | 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 $205,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $116,888 | | Amount paid for insurance broker fees | 10363 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | G0200 |
| Policy instance | 2 |
| Insurance contract or identification number | G0200 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 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 $2,070,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BBX3 |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0BBX3 | | Number of Individuals Covered | 408 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,796 | | 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 | 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 $17,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,796 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BBX3 |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0BBX3 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $1,454 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,454 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BBX3 |
| Policy instance | 5 |
| Insurance contract or identification number | GUG0BBX3 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $698 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,975 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $698 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBX3 |
| Policy instance | 6 |
| Insurance contract or identification number | GUC0BBX3 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $4,745 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,745 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BBX3 |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0BBX3 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $4,875 | | 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 | 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 $32,502 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,875 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BBX3 |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0BBX3 | | Number of Individuals Covered | 382 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,290 | | Total amount of fees paid to insurance company | USD $857 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,518 | | Amount paid for insurance broker fees | 857 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BBX3 |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL0BBX3 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $4,204 | | Total amount of fees paid to insurance company | USD $991 | | 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 & 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 $28,028 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,828 | | Amount paid for insurance broker fees | 991 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBX3 |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0BBX3 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $3,619 | | Total amount of fees paid to insurance company | USD $1,295 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $36,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,509 | | Amount paid for insurance broker fees | 1295 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 282920 |
| Policy instance | 4 |
| Insurance contract or identification number | 282920 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $88,070 | | 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 $1,840,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,269 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BBX3 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BBX3 | | Number of Individuals Covered | 382 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,024 | | Total amount of fees paid to insurance company | USD $387 | | 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 & 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 $10,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $677 | | Amount paid for insurance broker fees | 387 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278529 |
| Policy instance | 6 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $9,443 | | 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 | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $197,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,033 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0BBX3 |
| Policy instance | 7 |
| Insurance contract or identification number | GUG0BBX3 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $452 | | Total amount of fees paid to insurance company | USD $827 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,516 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $298 | | Amount paid for insurance broker fees | 827 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278529 |
| Policy instance | 1 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $397 | | Total amount of fees paid to insurance company | USD $88 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $397 | | Amount paid for insurance broker fees | 88 | | Additional information about fees paid to insurance broker | INCENTIVES, EDUCATION, COMMUNICATION, AND TRAINING | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 2 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $5,674 | | 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 $142,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,674 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0BBX3 ET AL |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0BBX3 ET AL | | Number of Individuals Covered | 237 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $12,615 | | Total amount of fees paid to insurance company | USD $6,640 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $114,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,322 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 6640 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910962 |
| Policy instance | 4 |
| Insurance contract or identification number | 910962 | | Number of Individuals Covered | 515 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $61,799 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $594,492 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,790 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 1 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $6,158 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $151,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,158 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 8210010 |
| Policy instance | 2 |
| Insurance contract or identification number | 8210010 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $250 | | Total amount of fees paid to insurance company | USD $29 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $2,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $250 | | Amount paid for insurance broker fees | 29 | | 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 | 0165024 |
| Policy instance | 3 |
| Insurance contract or identification number | 0165024 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $4,781 | | Total amount of fees paid to insurance company | USD $323 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $53,612 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,781 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910962 |
| Policy instance | 4 |
| Insurance contract or identification number | 910962 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $45,380 | | Total amount of fees paid to insurance company | USD $5,600 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $991,600 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,380 | | Amount paid for insurance broker fees | 5600 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BBX3 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BBX3 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $14,530 | | Total amount of fees paid to insurance company | USD $2,080 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $131,946 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,530 | | Amount paid for insurance broker fees | 2080 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278529 |
| Policy instance | 6 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $6,244 | | Total amount of fees paid to insurance company | USD $485 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $115,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,701 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 0165024 |
| Policy instance | 4 |
| Insurance contract or identification number | 0165024 | | Number of Individuals Covered | 373 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $9,352 | | Total amount of fees paid to insurance company | USD $938 | | Other welfare benefits provided | CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $42,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,352 | | Amount paid for insurance broker fees | 57 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910962 |
| Policy instance | 5 |
| Insurance contract or identification number | 910962 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $50,715 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $942,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,715 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | ACA7918551 |
| Policy instance | 6 |
| Insurance contract or identification number | ACA7918551 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $5,000 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $99,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $5,000 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010215488 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010215488 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $6,700 | | Total amount of fees paid to insurance company | USD $3,190 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $59,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,700 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 8210010 |
| Policy instance | 3 |
| Insurance contract or identification number | 8210010 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $168 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | LEGAL | | Welfare Benefit Premiums Paid to Carrier | USD $1,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $168 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278529 |
| Policy instance | 2 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $1,750 | | Total amount of fees paid to insurance company | USD $231 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,750 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 CA |
| Policy instance | 1 |
| Insurance contract or identification number | 120043 CA | | Number of Individuals Covered | 34 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $7,990 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $164,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,990 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 803839 |
| Policy instance | 1 |
| Insurance contract or identification number | 803839 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $35,163 | | Total amount of fees paid to insurance company | USD $3,122 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $644,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,163 | | Amount paid for insurance broker fees | 2964 | | Additional information about fees paid to insurance broker | 2014/2015 PPP ENGAGEMENT CREDIT | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 803839HNO |
| Policy instance | 2 |
| Insurance contract or identification number | 803839HNO | | Number of Individuals Covered | 49 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $9,882 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $200,200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,882 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 3 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $10,812 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $252,013 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,812 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278529 |
| Policy instance | 4 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $1,732 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,312 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,732 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 803839 |
| Policy instance | 1 |
| Insurance contract or identification number | 803839 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $31,813 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $592,307 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,813 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 803839 |
| Policy instance | 2 |
| Insurance contract or identification number | 803839 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $8,076 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $174,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,076 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 3 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $11,964 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $278,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,964 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278529 |
| Policy instance | 4 |
| Insurance contract or identification number | 278529 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $1,487 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,642 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,487 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0803839 |
| Policy instance | 1 |
| Insurance contract or identification number | 0803839 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $22,416 | | Total amount of fees paid to insurance company | USD $1,363 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $446,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,416 | | Amount paid for insurance broker fees | 1363 | | Additional information about fees paid to insurance broker | MM EARLY PREMIER PRODUCER 1/1/2013-4/30/13 RENEWAL BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US450981 |
| Policy instance | 2 |
| Insurance contract or identification number | US450981 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $13,124 | | Total amount of fees paid to insurance company | USD $900 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $257,821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,124 | | Amount paid for insurance broker fees | 900 | | Additional information about fees paid to insurance broker | MM EARLY PREMIER PRODUCER 1/1/2013-4/30/2013 RENEWAL BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 3 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $8,472 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $196,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,472 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00447085 |
| Policy instance | 4 |
| Insurance contract or identification number | 00447085 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $11,617 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 $148,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,168 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 803839 |
| Policy instance | 1 |
| Insurance contract or identification number | 803839 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $20,656 | | Total amount of fees paid to insurance company | USD $3,095 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $450,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,656 | | Amount paid for insurance broker fees | 3095 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | US450981 |
| Policy instance | 2 |
| Insurance contract or identification number | US450981 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $13,969 | | Total amount of fees paid to insurance company | USD $13,150 | | Welfare Benefit Premiums Paid to Carrier | USD $301,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,969 | | Amount paid for insurance broker fees | 13150 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 3 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $11,522 | | Welfare Benefit Premiums Paid to Carrier | USD $227,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,460 | | Insurance broker organization code? | 3 | | Insurance broker name | UNISURE INSURANCE SERVICES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 447085 |
| Policy instance | 4 |
| Insurance contract or identification number | 447085 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $15,247 | | Total amount of fees paid to insurance company | USD $70,268 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $181,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $106 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 70268 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker name | WELLS FARGO INSURANCE SERVICES USA |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 5 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $2,650 | | Welfare Benefit Premiums Paid to Carrier | USD $16,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,650 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICE USA |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 76307A |
| Policy instance | 1 |
| Insurance contract or identification number | 76307A | | Number of Individuals Covered | 55 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $14,354 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $417,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 447085 |
| Policy instance | 6 |
| Insurance contract or identification number | 447085 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $11,676 | | Total amount of fees paid to insurance company | USD $734 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $146,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 185176 |
| Policy instance | 3 |
| Insurance contract or identification number | 185176 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $12,900 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $240,786 | | 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 | 120043 |
| Policy instance | 2 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $9,197 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $215,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 531626 |
| Policy instance | 4 |
| Insurance contract or identification number | 531626 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $2,582 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 574630 |
| Policy instance | 5 |
| Insurance contract or identification number | 574630 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $2,087 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,789 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 531626 |
| Policy instance | 4 |
| Insurance contract or identification number | 531626 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2010-06-01 | | Insurance policy end date | 2011-05-31 | | Total amount of commissions paid to insurance broker | USD $2,106 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 185176 |
| Policy instance | 3 |
| Insurance contract or identification number | 185176 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $11,376 | | Total amount of fees paid to insurance company | USD $594 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $198,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 447085 |
| Policy instance | 5 |
| Insurance contract or identification number | 447085 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $8,309 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $100,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 76307A |
| Policy instance | 1 |
| Insurance contract or identification number | 76307A | | Number of Individuals Covered | 72 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $16,074 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $357,204 | | 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 | 120043 |
| Policy instance | 2 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $6,170 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $116,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5303750 |
| Policy instance | 6 |
| Insurance contract or identification number | 5303750 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $1,083 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,083 | | Insurance broker organization code? | 3 | | Insurance broker name | UNISURE INSURANCE SERVICES, INC. |
|
| HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 ) |
| Policy contract number | 68427A |
| Policy instance | 1 |
| Insurance contract or identification number | 68427A | | Number of Individuals Covered | 49 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2009-03-31 | | Total amount of commissions paid to insurance broker | USD $7,910 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $175,768 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,910 | | Insurance broker organization code? | 3 | | Insurance broker name | UNISURE INSURANCE SERVICES, INC. |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5357124 |
| Policy instance | 4 |
| Insurance contract or identification number | 5357124 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2008-09-30 | | Total amount of commissions paid to insurance broker | USD $646 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,307 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $646 | | Insurance broker organization code? | 3 | | Insurance broker name | UNISURE INSURANCE SERVICES, INC. |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 185176 |
| Policy instance | 3 |
| Insurance contract or identification number | 185176 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2009-03-31 | | Total amount of commissions paid to insurance broker | USD $11,376 | | Total amount of fees paid to insurance company | USD $594 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $198,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $11,376 | | Amount paid for insurance broker fees | 594 | | Additional information about fees paid to insurance broker | INCENTIVES, EDUCATION, COMMUNICATION AND TRAINING | | Insurance broker organization code? | 3 | | Insurance broker name | GIBSON MYERS & ASSOCIATES, INC. |
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 120043 |
| Policy instance | 2 |
| Insurance contract or identification number | 120043 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2008-02-01 | | Insurance policy end date | 2009-01-31 | | Total amount of commissions paid to insurance broker | USD $7,088 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,088 | | Insurance broker organization code? | 3 | | Insurance broker name | UNISURE INSURANCE SERVICES, INC. |
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| UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 ) |
| Policy contract number | 5303750 |
| Policy instance | 5 |
| Insurance contract or identification number | 5303750 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2008-04-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $737 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $737 | | Insurance broker organization code? | 3 | | Insurance broker name | UNICARE INSURANCE SERVICES, INC. |
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