401k Plan data: EMPLOYERS RESOURCE WRAP BENEFIT PLAN plan

EMPLOYERS RESOURCE WRAP BENEFIT PLAN 401k Plan overview

Plan Name	EMPLOYERS RESOURCE WRAP BENEFIT PLAN
Plan identification number	501

EMPLOYERS RESOURCE WRAP BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

EMPLOYERS RESOURCE has sponsored the creation of one or more 401k plans.

Company Name: EMPLOYERS RESOURCE

Employer identification number (EIN): 330688056

NAIC Classification: 541214
NAIC Description: Payroll Services

Additional information about EMPLOYERS RESOURCE

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 1996-01-08

Company Identification Number: C1959932

Legal Registered Office Address: 18002 Irvine Blvd Ste 108

Tustin
United States of America (USA)
92780

More information about EMPLOYERS RESOURCE

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYERS RESOURCE WRAP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-06-01
501 2018-06-01
501 2017-06-01 JACK EATON
501 2016-06-01 JACK EATON
501 2015-06-01 JACK EATON
501 2014-06-01 JACK EATON
501 2013-06-01 JACK EATON
501 2012-06-01 JACK EATON
501 2011-06-01 JACK EATON
501 2010-06-01 JACK EATON JACK EATON 2014-02-25
501 2009-06-01 JACK EATON JACK EATON 2014-02-25

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2019-06-01
501	2018-06-01
501	2017-06-01	JACK EATON
501	2016-06-01	JACK EATON
501	2015-06-01	JACK EATON
501	2014-06-01	JACK EATON
501	2013-06-01	JACK EATON
501	2012-06-01	JACK EATON
501	2011-06-01	JACK EATON
501	2010-06-01	JACK EATON	JACK EATON	2014-02-25
501	2009-06-01	JACK EATON	JACK EATON	2014-02-25

Plan Statistics for EMPLOYERS RESOURCE WRAP BENEFIT PLAN

401k plan membership statisitcs for EMPLOYERS RESOURCE WRAP BENEFIT PLAN

Measure Date Value
2019: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 593
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 565
Total of all active and inactive participants 2019-06-01 565
Total participants 2019-06-01 565
2018: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 483
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 593
Total of all active and inactive participants 2018-06-01 593
Total participants 2018-06-01 593
2017: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-06-01 554
Total number of active participants reported on line 7a of the Form 5500 2017-06-01 483
Total of all active and inactive participants 2017-06-01 483
Total participants 2017-06-01 483
2016: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-06-01 702
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 554
Total of all active and inactive participants 2016-06-01 554
Total participants 2016-06-01 554
2015: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 684
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 702
Total of all active and inactive participants 2015-06-01 702
Total participants 2015-06-01 0
2014: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 666
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 684
Total of all active and inactive participants 2014-06-01 684
Total participants 2014-06-01 0
2013: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-06-01 528
Total number of active participants reported on line 7a of the Form 5500 2013-06-01 516
Total of all active and inactive participants 2013-06-01 516
Total participants 2013-06-01 0
2012: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-06-01 566
Total number of active participants reported on line 7a of the Form 5500 2012-06-01 629
Number of retired or separated participants receiving benefits 2012-06-01 4
Total of all active and inactive participants 2012-06-01 633
Total participants 2012-06-01 0
2011: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-06-01 698
Total number of active participants reported on line 7a of the Form 5500 2011-06-01 647
Number of retired or separated participants receiving benefits 2011-06-01 3
Total of all active and inactive participants 2011-06-01 650
Total participants 2011-06-01 650
2010: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year 2010-06-01 714
Total number of active participants reported on line 7a of the Form 5500 2010-06-01 671
Number of retired or separated participants receiving benefits 2010-06-01 22
Total of all active and inactive participants 2010-06-01 693
Total participants 2010-06-01 693
2009: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 797
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 664
Number of retired or separated participants receiving benefits 2009-06-01 52
Total of all active and inactive participants 2009-06-01 716
Total participants 2009-06-01 716

Measure	Date	Value
2019: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	593
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	565
Total of all active and inactive participants	2019-06-01	565
Total participants	2019-06-01	565
2018: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	483
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	593
Total of all active and inactive participants	2018-06-01	593
Total participants	2018-06-01	593
2017: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-06-01	554
Total number of active participants reported on line 7a of the Form 5500	2017-06-01	483
Total of all active and inactive participants	2017-06-01	483
Total participants	2017-06-01	483
2016: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-06-01	702
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	554
Total of all active and inactive participants	2016-06-01	554
Total participants	2016-06-01	554
2015: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	684
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	702
Total of all active and inactive participants	2015-06-01	702
Total participants	2015-06-01	0
2014: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	666
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	684
Total of all active and inactive participants	2014-06-01	684
Total participants	2014-06-01	0
2013: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-06-01	528
Total number of active participants reported on line 7a of the Form 5500	2013-06-01	516
Total of all active and inactive participants	2013-06-01	516
Total participants	2013-06-01	0
2012: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-06-01	566
Total number of active participants reported on line 7a of the Form 5500	2012-06-01	629
Number of retired or separated participants receiving benefits	2012-06-01	4
Total of all active and inactive participants	2012-06-01	633
Total participants	2012-06-01	0
2011: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-06-01	698
Total number of active participants reported on line 7a of the Form 5500	2011-06-01	647
Number of retired or separated participants receiving benefits	2011-06-01	3
Total of all active and inactive participants	2011-06-01	650
Total participants	2011-06-01	650
2010: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year	2010-06-01	714
Total number of active participants reported on line 7a of the Form 5500	2010-06-01	671
Number of retired or separated participants receiving benefits	2010-06-01	22
Total of all active and inactive participants	2010-06-01	693
Total participants	2010-06-01	693
2009: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	797
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	664
Number of retired or separated participants receiving benefits	2009-06-01	52
Total of all active and inactive participants	2009-06-01	716
Total participants	2009-06-01	716

Form 5500 Responses for EMPLOYERS RESOURCE WRAP BENEFIT PLAN

2019: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes
2018: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes
2017: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2017 form 5500 responses
2017-06-01	Type of plan entity	Single employer plan
2017-06-01	Plan funding arrangement – Insurance	Yes
2017-06-01	Plan benefit arrangement – Insurance	Yes
2016: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2015: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes
2013: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2013 form 5500 responses
2013-06-01	Type of plan entity	Single employer plan
2013-06-01	Plan funding arrangement – Insurance	Yes
2013-06-01	Plan benefit arrangement – Insurance	Yes
2012: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2012 form 5500 responses
2012-06-01	Type of plan entity	Single employer plan
2012-06-01	Plan funding arrangement – Insurance	Yes
2012-06-01	Plan benefit arrangement – Insurance	Yes
2011: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2011 form 5500 responses
2011-06-01	Type of plan entity	Single employer plan
2011-06-01	Plan funding arrangement – Insurance	Yes
2011-06-01	Plan benefit arrangement – Insurance	Yes
2010: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2010 form 5500 responses
2010-06-01	Type of plan entity	Single employer plan
2010-06-01	Submission has been amended	No
2010-06-01	This submission is the final filing	No
2010-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-06-01	Plan is a collectively bargained plan	No
2010-06-01	Plan funding arrangement – Insurance	Yes
2010-06-01	Plan benefit arrangement – Insurance	Yes
2009: EMPLOYERS RESOURCE WRAP BENEFIT PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	First time form 5500 has been submitted	Yes
2009-06-01	Submission has been amended	No
2009-06-01	This submission is the final filing	No
2009-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-06-01	Plan is a collectively bargained plan	No
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	332
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $12,791
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,791
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

932980

Policy instance

Insurance contract or identification number	932980
Number of Individuals Covered	12
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $610
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $610

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

931379

Policy instance

Insurance contract or identification number	931379
Number of Individuals Covered	27
Insurance policy start date	2019-05-01
Insurance policy end date	2020-04-30
Total amount of commissions paid to insurance broker	USD $777
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $777
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

916624

Policy instance

Insurance contract or identification number	916624
Number of Individuals Covered	32
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $1,750
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,704
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
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

914892

Policy instance

Insurance contract or identification number	914892
Number of Individuals Covered	30
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $2,616
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,616
Insurance broker organization code?	3

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235493

Policy instance

Insurance contract or identification number	235493
Number of Individuals Covered	11
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $7,133
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $101,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,133
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	13
Insurance policy start date	2019-06-01
Insurance policy end date	2020-06-01
Total amount of commissions paid to insurance broker	USD $885
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $885
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

341990

Policy instance

Insurance contract or identification number	341990
Number of Individuals Covered	21
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $9,673
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,696
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	15
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,853
Total amount of fees paid to insurance company	USD $159
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $628
Amount paid for insurance broker fees	85
Insurance broker organization code?	3

CENTRAL UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61883 )

Policy contract number

898641

Policy instance

Insurance contract or identification number	898641
Number of Individuals Covered	10
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $864
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $511

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	62
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $1,571
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,571
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

931379

Policy instance

Insurance contract or identification number	931379
Number of Individuals Covered	28
Insurance policy start date	2019-05-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $73
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $73
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	359
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $10,622
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $163,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,622
Insurance broker organization code?	3

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	81
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,229
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,229
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

916624

Policy instance

Insurance contract or identification number	916624
Number of Individuals Covered	37
Insurance policy start date	2018-09-01
Insurance policy end date	2019-08-31
Total amount of commissions paid to insurance broker	USD $1,802
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $12,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,802
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

914892

Policy instance

Insurance contract or identification number	914892
Number of Individuals Covered	17
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $3,640
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,640
Insurance broker organization code?	3

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235493

Policy instance

Insurance contract or identification number	235493
Number of Individuals Covered	12
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $6,718
Total amount of fees paid to insurance company	USD $3,360
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,718
Amount paid for insurance broker fees	3360
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	15
Insurance policy start date	2018-06-01
Insurance policy end date	2019-06-01
Total amount of commissions paid to insurance broker	USD $3,280
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,280
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

341990

Policy instance

Insurance contract or identification number	341990
Number of Individuals Covered	20
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $10,084
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $130,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,083
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	9
Insurance policy start date	2018-06-01
Insurance policy end date	2019-04-01
Total amount of commissions paid to insurance broker	USD $637
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $637
Insurance broker organization code?	3

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	15
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,535
Total amount of fees paid to insurance company	USD $96
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $512
Amount paid for insurance broker fees	41
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	319
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $10,653
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,756
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,653
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235493

Policy instance

Insurance contract or identification number	235493
Number of Individuals Covered	10
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $8,494
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $80,894
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,663
Insurance broker organization code?	3
Insurance broker name	WORD & BROWN INSURANCE ADMINIS

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	23
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $3,545
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,545
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

341990

Policy instance

Insurance contract or identification number	341990
Number of Individuals Covered	21
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $9,904
Total amount of fees paid to insurance company	USD $425
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,664
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,058
Amount paid for insurance broker fees	425
Insurance broker organization code?	3
Insurance broker name	LISI, INC.

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	83
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $1,436
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,593
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,436
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	16
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $2,323
Total amount of fees paid to insurance company	USD $243
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $678
Amount paid for insurance broker fees	185
Insurance broker organization code?	3
Insurance broker name	SARAH COURTNEY KNAPP

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	13
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $1,125
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,125
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

898641

Policy instance

Insurance contract or identification number	898641
Number of Individuals Covered	8
Insurance policy start date	2017-06-01
Insurance policy end date	2018-05-31
Total amount of commissions paid to insurance broker	USD $634
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $634
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

898641

Policy instance

Insurance contract or identification number	898641
Number of Individuals Covered	4
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $913
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $913
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235493

Policy instance

Insurance contract or identification number	235493
Number of Individuals Covered	13
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $7,591
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $108,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,591
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

046-2799-00

Policy instance

Insurance contract or identification number	046-2799-00
Number of Individuals Covered	18
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $822
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $5,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $822
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	38
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $5,380
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,380
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	9
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $131
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $131
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

37136

Policy instance

Insurance contract or identification number	37136
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $933
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $933
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	111
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $17,419
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $583,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,419
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	23
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $5,403
Total amount of fees paid to insurance company	USD $954
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,232
Amount paid for insurance broker fees	505
Insurance broker organization code?	3
Insurance broker name	CLAUDIA MARABOTO

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	15
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $2,247
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,441
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,247
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	471
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $14,588
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $222,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,588
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	18
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $4,597
Total amount of fees paid to insurance company	USD $1,148
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,099
Amount paid for insurance broker fees	467
Insurance broker organization code?	3
Insurance broker name	ERIC WEBER SWANSON

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	21
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,235
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,235
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	10
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $126
Other welfare benefits provided	ACUPUNCTURE & CHIROPRACTIC
Welfare Benefit Premiums Paid to Carrier	USD $1,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $126
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	398
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $20,436
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $393,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,436
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	152
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $24,125
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $801,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,962
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	7
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,699
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,552
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	38
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $5,380
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,380
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

046-2799-00

Policy instance

Insurance contract or identification number	046-2799-00
Number of Individuals Covered	16
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $1,627
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	VOL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,627
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICES

UNITED HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

245493

Policy instance

Insurance contract or identification number	245493
Number of Individuals Covered	15
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $4,181
Welfare Benefit Premiums Paid to Carrier	USD $132,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,181
Insurance broker organization code?	3
Insurance broker name	WORD & BROWN INSURANCE

KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )

Policy contract number

KANAWHA -898641

Policy instance

Insurance contract or identification number	KANAWHA -898641
Number of Individuals Covered	9
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $211
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $211
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	43
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $5,007
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,007
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	18
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $158
Other welfare benefits provided	ACUPUNCTURE & CHIROPRACTIC
Welfare Benefit Premiums Paid to Carrier	USD $1,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $158
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	388
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $18,557
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $288,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,557
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

64890A

Policy instance

Insurance contract or identification number	64890A
Number of Individuals Covered	52
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $33,579
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $717,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,579
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	22
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,939
Total amount of fees paid to insurance company	USD $779
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,152
Amount paid for insurance broker fees	252
Insurance broker organization code?	3
Insurance broker name	STABELL INSURANCE SERVICE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	26
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $3,260
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,260
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	11
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $2,848
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $86,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,848
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	158
Insurance policy start date	2013-06-01
Insurance policy end date	2014-05-31
Total amount of commissions paid to insurance broker	USD $25,537
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $842,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,537
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	48
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $5,850
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,850
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	36
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $3,801
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $35,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,801
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	24
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,870
Total amount of fees paid to insurance company	USD $621
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Insurance broker name	JOHN DAVID EVENGELISTA

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

64890A

Policy instance

Insurance contract or identification number	64890A
Number of Individuals Covered	77
Insurance policy start date	2012-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $42,353
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $863,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,353
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

612174

Policy instance

Insurance contract or identification number	612174
Number of Individuals Covered	390
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $19,578
Total amount of fees paid to insurance company	USD $1,369
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $356,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,578
Amount paid for insurance broker fees	1369
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	183
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $28,760
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $971,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $28,760
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	25
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $4,478
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $164,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,478
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	19
Insurance policy start date	2012-06-01
Insurance policy end date	2013-05-31
Total amount of commissions paid to insurance broker	USD $201
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	158
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $39,257
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,243,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	36
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $4,322
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $39,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	44
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $426
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,262
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

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	13
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $4,158
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

151809

Policy instance

Insurance contract or identification number	151809
Number of Individuals Covered	48
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $5,883
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,414
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

64890A

Policy instance

Insurance contract or identification number	64890A
Number of Individuals Covered	99
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $49,693
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,036,168
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

00396979

Policy instance

Insurance contract or identification number	00396979
Number of Individuals Covered	531
Insurance policy start date	2011-06-01
Insurance policy end date	2012-05-31
Total amount of commissions paid to insurance broker	USD $10,411
Total amount of fees paid to insurance company	USD $13,395
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $388,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	29
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,956
Total amount of fees paid to insurance company	USD $1,256
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	68
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $613
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 $6,131
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

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	14
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,557
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 $113,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	41
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,676
Total amount of fees paid to insurance company	USD $2,101
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	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 $42,697
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

00396979

Policy instance

Insurance contract or identification number	00396979
Number of Individuals Covered	567
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $11,715
Total amount of fees paid to insurance company	USD $1,199
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 $461,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	36
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $3,830
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	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 $30,812
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

64890A

Policy instance

Insurance contract or identification number	64890A
Number of Individuals Covered	134
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $54,705
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 $1,199,861
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

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	173
Insurance policy start date	2010-06-01
Insurance policy end date	2011-05-31
Total amount of commissions paid to insurance broker	USD $32,673
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 $1,054,109
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

64890A

Policy instance

Insurance contract or identification number	64890A
Number of Individuals Covered	170
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $62,700
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 $1,353,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $62,700
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICES

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

570392

Policy instance

Insurance contract or identification number	570392
Number of Individuals Covered	36
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $3,623
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	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 $30,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,623
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00396979

Policy instance

Insurance contract or identification number	00396979
Number of Individuals Covered	589
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $10,404
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 $414,536
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,404
Insurance broker organization code?	3
Insurance broker name	ER INSURANCE SERVICES

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

225017

Policy instance

Insurance contract or identification number	225017
Number of Individuals Covered	155
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $26,050
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 $868,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $-30,675
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

37136

Policy instance

Insurance contract or identification number	37136
Number of Individuals Covered	14
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $2,793
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 $90,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,793
Insurance broker organization code?	3
Insurance broker name	JAMES BULOTTI

LANDMARK HEALTHPLAN (National Association of Insurance Commissioners NAIC id number: 52414 )

Policy contract number

LH408W*000

Policy instance

Insurance contract or identification number	LH408W*000
Number of Individuals Covered	64
Insurance policy start date	2009-06-01
Insurance policy end date	2010-05-31
Total amount of commissions paid to insurance broker	USD $529
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 $5,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $529
Insurance broker organization code?	3
Insurance broker name	INTERWEST INSURANCE SERVICE

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3044807

Policy instance

Insurance contract or identification number	E3044807
Number of Individuals Covered	41
Insurance policy start date	2009-01-01
Insurance policy end date	2009-12-31
Total amount of commissions paid to insurance broker	USD $6,851
Total amount of fees paid to insurance company	USD $1,854
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	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 $47,423
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
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Insurance broker name	ER INSURANCE SERVICES

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Company Name:	EMPLOYERS RESOURCE
Employer identification number (EIN):	330688056
NAIC Classification:	541214
NAIC Description:	Payroll Services

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	1996-01-08
Company Identification Number:	C1959932
Legal Registered Office Address:	18002 Irvine Blvd Ste 108 Tustin United States of America (USA) 92780