FOREVER 21, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FOREVER 21 EMPLOYEE BENEFIT PLANS
Measure | Date | Value |
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2022: FOREVER 21 EMPLOYEE BENEFIT PLANS 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 0 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 0 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 0 |
2021: FOREVER 21 EMPLOYEE BENEFIT PLANS 2021 401k membership |
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Total participants, beginning-of-year | 2021-09-01 | 1,324 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 1,310 |
Number of retired or separated participants receiving benefits | 2021-09-01 | 33 |
Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
Total of all active and inactive participants | 2021-09-01 | 1,343 |
2020: FOREVER 21 EMPLOYEE BENEFIT PLANS 2020 401k membership |
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Total participants, beginning-of-year | 2020-09-01 | 1,303 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 1,347 |
Number of retired or separated participants receiving benefits | 2020-09-01 | 39 |
Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
Total of all active and inactive participants | 2020-09-01 | 1,386 |
2019: FOREVER 21 EMPLOYEE BENEFIT PLANS 2019 401k membership |
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Total participants, beginning-of-year | 2019-09-01 | 4,016 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 1,896 |
Number of retired or separated participants receiving benefits | 2019-09-01 | 52 |
Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 4 |
Total of all active and inactive participants | 2019-09-01 | 1,952 |
Number of employers contributing to the scheme | 2019-09-01 | 0 |
2018: FOREVER 21 EMPLOYEE BENEFIT PLANS 2018 401k membership |
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Total participants, beginning-of-year | 2018-09-01 | 1,030 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 971 |
Number of retired or separated participants receiving benefits | 2018-09-01 | 41 |
Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
Total of all active and inactive participants | 2018-09-01 | 1,012 |
Number of employers contributing to the scheme | 2018-09-01 | 0 |
2017: FOREVER 21 EMPLOYEE BENEFIT PLANS 2017 401k membership |
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Total participants, beginning-of-year | 2017-09-01 | 3,749 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 6,817 |
Number of retired or separated participants receiving benefits | 2017-09-01 | 18 |
Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
Total of all active and inactive participants | 2017-09-01 | 6,835 |
Number of employers contributing to the scheme | 2017-09-01 | 0 |
2016: FOREVER 21 EMPLOYEE BENEFIT PLANS 2016 401k membership |
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Total participants, beginning-of-year | 2016-09-01 | 4,179 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 3,693 |
Number of retired or separated participants receiving benefits | 2016-09-01 | 28 |
Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 28 |
Total of all active and inactive participants | 2016-09-01 | 3,749 |
2015: FOREVER 21 EMPLOYEE BENEFIT PLANS 2015 401k membership |
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Total participants, beginning-of-year | 2015-09-01 | 5,621 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 4,437 |
Number of retired or separated participants receiving benefits | 2015-09-01 | 39 |
Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 794 |
Total of all active and inactive participants | 2015-09-01 | 5,270 |
2014: FOREVER 21 EMPLOYEE BENEFIT PLANS 2014 401k membership |
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Total participants, beginning-of-year | 2014-09-01 | 4,444 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 4,243 |
Number of retired or separated participants receiving benefits | 2014-09-01 | 25 |
Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 863 |
Total of all active and inactive participants | 2014-09-01 | 5,131 |
2013: FOREVER 21 EMPLOYEE BENEFIT PLANS 2013 401k membership |
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Total participants, beginning-of-year | 2013-09-01 | 6,686 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 4,444 |
Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 0 |
Total of all active and inactive participants | 2013-09-01 | 4,444 |
2012: FOREVER 21 EMPLOYEE BENEFIT PLANS 2012 401k membership |
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Total participants, beginning-of-year | 2012-09-01 | 6,236 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 6,686 |
Number of retired or separated participants receiving benefits | 2012-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 0 |
Total of all active and inactive participants | 2012-09-01 | 6,686 |
2011: FOREVER 21 EMPLOYEE BENEFIT PLANS 2011 401k membership |
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Total participants, beginning-of-year | 2011-09-01 | 4,194 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 5,834 |
Number of retired or separated participants receiving benefits | 2011-09-01 | 402 |
Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
Total of all active and inactive participants | 2011-09-01 | 6,236 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-09-01 | 0 |
Total participants | 2011-09-01 | 6,236 |
Number of participants with account balances | 2011-09-01 | 0 |
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2011-09-01 | 0 |
2009: FOREVER 21 EMPLOYEE BENEFIT PLANS 2009 401k membership |
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Total participants, beginning-of-year | 2009-09-01 | 2,700 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 3,180 |
Number of retired or separated participants receiving benefits | 2009-09-01 | 18 |
Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 49 |
Total of all active and inactive participants | 2009-09-01 | 3,247 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-09-01 | 0 |
Total participants | 2009-09-01 | 3,247 |
Number of participants with account balances | 2009-09-01 | 0 |
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-09-01 | 0 |
2022: FOREVER 21 EMPLOYEE BENEFIT PLANS 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Submission has been amended | No |
2022-01-01 | This submission is the final filing | Yes |
2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-01-01 | Plan is a collectively bargained plan | No |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: FOREVER 21 EMPLOYEE BENEFIT PLANS 2021 form 5500 responses |
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2021-09-01 | Type of plan entity | Single employer plan |
2021-09-01 | Submission has been amended | No |
2021-09-01 | This submission is the final filing | No |
2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2021-09-01 | Plan is a collectively bargained plan | No |
2021-09-01 | Plan funding arrangement – Insurance | Yes |
2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-09-01 | Plan benefit arrangement – Insurance | Yes |
2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: FOREVER 21 EMPLOYEE BENEFIT PLANS 2020 form 5500 responses |
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2020-09-01 | Type of plan entity | Single employer plan |
2020-09-01 | Submission has been amended | No |
2020-09-01 | This submission is the final filing | No |
2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-09-01 | Plan is a collectively bargained plan | No |
2020-09-01 | Plan funding arrangement – Insurance | Yes |
2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-09-01 | Plan benefit arrangement – Insurance | Yes |
2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: FOREVER 21 EMPLOYEE BENEFIT PLANS 2019 form 5500 responses |
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2019-09-01 | Type of plan entity | Single employer plan |
2019-09-01 | Plan funding arrangement – Insurance | Yes |
2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-09-01 | Plan benefit arrangement – Insurance | Yes |
2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: FOREVER 21 EMPLOYEE BENEFIT PLANS 2018 form 5500 responses |
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2018-09-01 | Type of plan entity | Single employer plan |
2018-09-01 | Plan funding arrangement – Insurance | Yes |
2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-09-01 | Plan benefit arrangement – Insurance | Yes |
2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: FOREVER 21 EMPLOYEE BENEFIT PLANS 2017 form 5500 responses |
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2017-09-01 | Type of plan entity | Single employer plan |
2017-09-01 | Plan funding arrangement – Insurance | Yes |
2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-09-01 | Plan benefit arrangement – Insurance | Yes |
2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: FOREVER 21 EMPLOYEE BENEFIT PLANS 2016 form 5500 responses |
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2016-09-01 | Type of plan entity | Single employer plan |
2016-09-01 | Submission has been amended | No |
2016-09-01 | This submission is the final filing | No |
2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-09-01 | Plan is a collectively bargained plan | No |
2016-09-01 | Plan funding arrangement – Insurance | Yes |
2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-09-01 | Plan benefit arrangement – Insurance | Yes |
2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: FOREVER 21 EMPLOYEE BENEFIT PLANS 2015 form 5500 responses |
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2015-09-01 | Type of plan entity | Single employer plan |
2015-09-01 | Submission has been amended | No |
2015-09-01 | This submission is the final filing | No |
2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-09-01 | Plan is a collectively bargained plan | No |
2015-09-01 | Plan funding arrangement – Insurance | Yes |
2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-09-01 | Plan benefit arrangement – Insurance | Yes |
2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: FOREVER 21 EMPLOYEE BENEFIT PLANS 2014 form 5500 responses |
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2014-09-01 | Type of plan entity | Single employer plan |
2014-09-01 | Submission has been amended | No |
2014-09-01 | This submission is the final filing | No |
2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-09-01 | Plan is a collectively bargained plan | No |
2014-09-01 | Plan funding arrangement – Insurance | Yes |
2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-09-01 | Plan benefit arrangement – Insurance | Yes |
2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: FOREVER 21 EMPLOYEE BENEFIT PLANS 2013 form 5500 responses |
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2013-09-01 | Type of plan entity | Single employer plan |
2013-09-01 | Submission has been amended | No |
2013-09-01 | This submission is the final filing | No |
2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-09-01 | Plan is a collectively bargained plan | No |
2013-09-01 | Plan funding arrangement – Insurance | Yes |
2013-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-09-01 | Plan benefit arrangement – Insurance | Yes |
2013-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: FOREVER 21 EMPLOYEE BENEFIT PLANS 2012 form 5500 responses |
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2012-09-01 | Type of plan entity | Single employer plan |
2012-09-01 | Submission has been amended | No |
2012-09-01 | This submission is the final filing | No |
2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-09-01 | Plan is a collectively bargained plan | No |
2012-09-01 | Plan funding arrangement – Insurance | Yes |
2012-09-01 | Plan benefit arrangement – Insurance | Yes |
2011: FOREVER 21 EMPLOYEE BENEFIT PLANS 2011 form 5500 responses |
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2011-09-01 | Type of plan entity | Single employer plan |
2011-09-01 | Submission has been amended | No |
2011-09-01 | This submission is the final filing | No |
2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-09-01 | Plan is a collectively bargained plan | No |
2011-09-01 | Plan funding arrangement – Insurance | Yes |
2011-09-01 | Plan benefit arrangement – Insurance | Yes |
2009: FOREVER 21 EMPLOYEE BENEFIT PLANS 2009 form 5500 responses |
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2009-09-01 | Type of plan entity | Single employer plan |
2009-09-01 | Submission has been amended | No |
2009-09-01 | This submission is the final filing | No |
2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-09-01 | Plan is a collectively bargained plan | No |
2009-09-01 | Plan funding arrangement – Insurance | Yes |
2009-09-01 | Plan benefit arrangement – Insurance | Yes |
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 0012652368 |
Policy instance | 17 |
Insurance contract or identification number | 0012652368 | Number of Individuals Covered | 207 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $18,639 | Total amount of fees paid to insurance company | USD $2,271 | 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 | 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 $28,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,639 | Amount paid for insurance broker fees | 2271 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 231108 |
Policy instance | 3 |
Insurance contract or identification number | 231108 | Number of Individuals Covered | 516 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $-18 | 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 $200,000 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $-18 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474164 |
Policy instance | 4 |
Insurance contract or identification number | 474164 | Number of Individuals Covered | 465 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $2,722 | 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 & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | 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 | Amount paid for insurance broker fees | 2722 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474165 |
Policy instance | 5 |
Insurance contract or identification number | 474165 | Number of Individuals Covered | 498 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $19,129 | Total amount of fees paid to insurance company | USD $2,584 | 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 | 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 $127,526 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $19,129 | Amount paid for insurance broker fees | 2584 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474166 |
Policy instance | 6 |
Insurance contract or identification number | 474166 | Number of Individuals Covered | 319 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | 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 $193,067 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | R0792754 |
Policy instance | 7 |
Insurance contract or identification number | R0792754 | Number of Individuals Covered | 15 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,070 | 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 | 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 | 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 $1,265 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,070 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0792762 |
Policy instance | 8 |
Insurance contract or identification number | R0792762 | Number of Individuals Covered | 1920 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $96,869 | Total amount of fees paid to insurance company | USD $16,647 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL CARE | 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 $279,896 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $96,869 | Amount paid for insurance broker fees | 16647 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 0012652368 |
Policy instance | 9 |
Insurance contract or identification number | 0012652368 | Number of Individuals Covered | 296 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $18,322 | Total amount of fees paid to insurance company | USD $2,217 | 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 | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $26,269 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,322 | Amount paid for insurance broker fees | 2217 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474164 |
Policy instance | 18 |
Insurance contract or identification number | 474164 | Number of Individuals Covered | 0 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | ACCIDENTL DEATH & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30027120 |
Policy instance | 11 |
Insurance contract or identification number | 30027120 | Number of Individuals Covered | 1434 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | 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 $125,232 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30027120 |
Policy instance | 12 |
Insurance contract or identification number | 30027120 | Number of Individuals Covered | 1450 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $37,906 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
Policy contract number | SP0006207 |
Policy instance | 13 |
Insurance contract or identification number | SP0006207 | Number of Individuals Covered | 36 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,780 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | MAJOR MEDICAL, ORGAN & TISSUE TRANSPLANT, TELECONSULTA | 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 $35,606 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,780 | Insurance broker organization code? | 3 |
|
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3343783 |
Policy instance | 14 |
Insurance contract or identification number | 3343783 | Number of Individuals Covered | 1684 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $204,385 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | R0792754 |
Policy instance | 15 |
Insurance contract or identification number | R0792754 | Number of Individuals Covered | 11 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,074 | 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 | 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 $1,435 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,074 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0792762 |
Policy instance | 16 |
Insurance contract or identification number | R0792762 | Number of Individuals Covered | 1483 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $27,047 | Total amount of fees paid to insurance company | USD $4,099 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL CARE | 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 $103,389 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $27,047 | Amount paid for insurance broker fees | 4099 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 603668 |
Policy instance | 2 |
Insurance contract or identification number | 603668 | Number of Individuals Covered | 56 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2020-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $345,087 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3343783 |
Policy instance | 1 |
Insurance contract or identification number | 3343783 | Number of Individuals Covered | 1685 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $828,508 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474165 |
Policy instance | 19 |
Insurance contract or identification number | 474165 | Number of Individuals Covered | 0 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474166 |
Policy instance | 20 |
Insurance contract or identification number | 474166 | Number of Individuals Covered | 0 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
Policy contract number | SP0006207 |
Policy instance | 10 |
Insurance contract or identification number | SP0006207 | Number of Individuals Covered | 36 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $6,427 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | MAJOR MEDICAL, ORGAN & TISSUE TRANSPLANT, TELECONSULTA | 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 $142,351 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,427 | Insurance broker organization code? | 3 |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30027120 |
Policy instance | 12 |
Insurance contract or identification number | 30027120 | Number of Individuals Covered | 1482 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | 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 $192,861 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 ) |
Policy contract number | SP0006207 |
Policy instance | 11 |
Insurance contract or identification number | SP0006207 | Number of Individuals Covered | 37 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $7,543 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | MAJOR MEDICAL, ORGAN & TISSUE TRANSPLANT, TELECONSULTA | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $139,132 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,543 | Insurance broker organization code? | 3 |
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PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
Policy contract number | 0012652368 |
Policy instance | 10 |
Insurance contract or identification number | 0012652368 | Number of Individuals Covered | 379 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $22,585 | Total amount of fees paid to insurance company | USD $2,761 | 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 | 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 $23,561 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,585 | Amount paid for insurance broker fees | 2761 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0792762 |
Policy instance | 9 |
Insurance contract or identification number | R0792762 | Number of Individuals Covered | 2696 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $138,914 | Total amount of fees paid to insurance company | USD $31,592 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL CARE | 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 $313,123 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $138,914 | Amount paid for insurance broker fees | 31592 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | R0792754 |
Policy instance | 8 |
Insurance contract or identification number | R0792754 | Number of Individuals Covered | 11 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $774 | 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 | 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 $835 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $774 | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474165 |
Policy instance | 6 |
Insurance contract or identification number | 474165 | Number of Individuals Covered | 695 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $5,231 | Total amount of fees paid to insurance company | USD $839 | 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 | 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 $33,539 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,231 | Amount paid for insurance broker fees | 839 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474164 |
Policy instance | 5 |
Insurance contract or identification number | 474164 | Number of Individuals Covered | 759 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $1,292 | 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 & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | 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 $51,679 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 1292 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 231108 |
Policy instance | 4 |
Insurance contract or identification number | 231108 | Number of Individuals Covered | 517 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $109,712 | 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 $4,868,645 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $109,712 | Insurance broker organization code? | 3 |
|
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 603668 |
Policy instance | 3 |
Insurance contract or identification number | 603668 | Number of Individuals Covered | 59 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $8,889 | 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 $439,884 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,889 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 32234 |
Policy instance | 2 |
Insurance contract or identification number | 32234 | Number of Individuals Covered | 28 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-01-31 | Total amount of commissions paid to insurance broker | USD $3,455 | 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 $80,315 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,455 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 32234 |
Policy instance | 1 |
Insurance contract or identification number | 32234 | Number of Individuals Covered | 30 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $8,779 | 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 $246,638 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,779 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 0865244 |
Policy instance | 13 |
Insurance contract or identification number | 0865244 | Number of Individuals Covered | 2754 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,281,067 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474166 |
Policy instance | 7 |
Insurance contract or identification number | 474166 | Number of Individuals Covered | 393 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | 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 $39,248 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 474164 |
Policy instance | 3 |
Insurance contract or identification number | 474164 | Number of Individuals Covered | 759 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $1,292 | 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 $51,679 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $0 | Amount paid for insurance broker fees | 1292 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 865244 |
Policy instance | 1 |
Insurance contract or identification number | 865244 | Number of Individuals Covered | 5051 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,145,287 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 32234 |
Policy instance | 2 |
Insurance contract or identification number | 32234 | Number of Individuals Covered | 106 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $17,213 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $536,829 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,213 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 231108 |
Policy instance | 4 |
Insurance contract or identification number | 231108 | Number of Individuals Covered | 1621 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $291,778 | Total amount of fees paid to insurance company | USD $83 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $9,960,781 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $282,889 | Amount paid for insurance broker fees | 83 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 69536 |
Policy instance | 5 |
Insurance contract or identification number | 69536 | Number of Individuals Covered | 1337 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $287,479 | Total amount of fees paid to insurance company | USD $34,559 | 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 | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $1,128,931 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $267,200 | Amount paid for insurance broker fees | 34559 | Additional information about fees paid to insurance broker | SERVICE FEE | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 32234 |
Policy instance | 2 |
Insurance contract or identification number | 32234 | Number of Individuals Covered | 126 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $8,810 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $471,387 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,810 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
Policy contract number | 69536 |
Policy instance | 4 |
Insurance contract or identification number | 69536 | Number of Individuals Covered | 1391 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $201,499 | Total amount of fees paid to insurance company | USD $34,331 | 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 | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $1,003,133 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $181,110 | Amount paid for insurance broker fees | 34111 | Additional information about fees paid to insurance broker | SERVICE FEE | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 231108 |
Policy instance | 3 |
Insurance contract or identification number | 231108 | Number of Individuals Covered | 2035 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $284,221 | Total amount of fees paid to insurance company | USD $318 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $8,706,428 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $284,221 | Amount paid for insurance broker fees | 318 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 865244 |
Policy instance | 1 |
Insurance contract or identification number | 865244 | Number of Individuals Covered | 5778 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,175,268 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 32234 |
Policy instance | 2 |
Insurance contract or identification number | 32234 | Number of Individuals Covered | 46 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $3,764 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $211,184 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,764 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WILLIS OF CALIFORNIA, INC. |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 74597 |
Policy instance | 3 |
Insurance contract or identification number | 74597 | Number of Individuals Covered | 1 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $6,000 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 30027120 |
Policy instance | 4 |
Insurance contract or identification number | 30027120 | Number of Individuals Covered | 3531 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $319,153 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
Policy contract number | 69536 |
Policy instance | 5 |
Insurance contract or identification number | 69536 | Number of Individuals Covered | 1352 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $354,952 | Total amount of fees paid to insurance company | USD $38,427 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $1,044,235 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $336,518 | Amount paid for insurance broker fees | 28775 | Additional information about fees paid to insurance broker | SERVICE FEE | Insurance broker organization code? | 3 | Insurance broker name | WILLIS OF CALIFORNIA, INC. |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 231108 |
Policy instance | 6 |
Insurance contract or identification number | 231108 | Number of Individuals Covered | 1983 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $261,497 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Welfare Benefit Premiums Paid to Carrier | USD $8,776,119 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $261,439 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | CRYSTAL AND COMPANY |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 865244 |
Policy instance | 1 |
Insurance contract or identification number | 865244 | Number of Individuals Covered | 5931 | Insurance policy start date | 2016-10-01 | Insurance policy end date | 2017-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,298,052 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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