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M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan NameM.C., LLC HEALTH AND WELFARE BENEFITS PLAN
Plan identification number 501

M.C., LLC HEALTH AND WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision

401k Sponsoring company profile

MC LLC has sponsored the creation of one or more 401k plans.

Company Name:MC LLC
Employer identification number (EIN):331109067
NAIC Classification:811190

Additional information about MC LLC

Jurisdiction of Incorporation: California Department of State
Incorporation Date:
Company Identification Number: 200433610078

More information about MC LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan M.C., LLC HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01MARC FANTICOLA
5012017-01-01
5012016-01-01
5012015-07-01MARC FANTICOLA
5012014-07-01MARC A FANTICOLA
5012013-07-01MARC A FANTICOLA
5012012-07-01MC LLC
5012011-07-01MARC FANTICOLA
5012009-07-01MC LLC
5012008-07-01MC LLC
5012005-07-01MC LLC

Plan Statistics for M.C., LLC HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for M.C., LLC HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2022: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01358
Total number of active participants reported on line 7a of the Form 55002022-01-01290
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-0110
Total of all active and inactive participants2022-01-01302
2021: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01255
Total number of active participants reported on line 7a of the Form 55002021-01-01250
Number of retired or separated participants receiving benefits2021-01-012
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01252
2020: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01210
Total number of active participants reported on line 7a of the Form 55002020-01-01255
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01255
2019: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01251
Total number of active participants reported on line 7a of the Form 55002019-01-01209
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01210
2018: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01254
Total number of active participants reported on line 7a of the Form 55002018-01-01250
Number of retired or separated participants receiving benefits2018-01-011
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01251
2017: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01260
Total number of active participants reported on line 7a of the Form 55002017-01-01254
Total of all active and inactive participants2017-01-01254
Total participants2017-01-01254
2016: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01174
Total number of active participants reported on line 7a of the Form 55002016-01-01260
Total of all active and inactive participants2016-01-01260
Total participants2016-01-01260
2015: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01114
Total number of active participants reported on line 7a of the Form 55002015-07-01173
Number of retired or separated participants receiving benefits2015-07-011
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01174
2014: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01242
Total number of active participants reported on line 7a of the Form 55002014-07-01154
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01154
2013: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01191
Total number of active participants reported on line 7a of the Form 55002013-07-01242
Number of retired or separated participants receiving benefits2013-07-010
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-01242
2012: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01191
Total number of active participants reported on line 7a of the Form 55002012-07-01191
Total of all active and inactive participants2012-07-01191
Total participants2012-07-01191
2011: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01468
Total number of active participants reported on line 7a of the Form 55002011-07-01273
Total of all active and inactive participants2011-07-01273
Total participants2011-07-01273
2009: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-07-01345
Total number of active participants reported on line 7a of the Form 55002009-07-01463
Total of all active and inactive participants2009-07-01463
Total participants2009-07-01463
2008: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-07-01134
Total number of active participants reported on line 7a of the Form 55002008-07-01345
Total of all active and inactive participants2008-07-01345
Total participants2008-07-01345
2005: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year2005-07-01151
Total number of active participants reported on line 7a of the Form 55002005-07-01151
Total of all active and inactive participants2005-07-01151
Total participants2005-07-01151

Form 5500 Responses for M.C., LLC HEALTH AND WELFARE BENEFITS PLAN

2022: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes
2014: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedYes
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2009: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – InsuranceYes
2008: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-07-01Type of plan entitySingle employer plan
2008-07-01Plan funding arrangement – InsuranceYes
2008-07-01Plan benefit arrangement – InsuranceYes
2005: M.C., LLC HEALTH AND WELFARE BENEFITS PLAN 2005 form 5500 responses
2005-07-01Type of plan entitySingle employer plan
2005-07-01First time form 5500 has been submittedYes
2005-07-01Plan funding arrangement – InsuranceYes
2005-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 4
Insurance contract or identification number269718
Number of Individuals Covered135
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $29,141
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $614,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,141
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 3
Insurance contract or identification number602917
Number of Individuals Covered68
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $21,047
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $439,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,047
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282782
Policy instance 2
Insurance contract or identification number282782
Number of Individuals Covered152
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $41,360
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $833,254
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,360
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00580098
Policy instance 1
Insurance contract or identification number00580098
Number of Individuals Covered254
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $14,994
Total amount of fees paid to insurance companyUSD $4,425
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $126,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,994
Amount paid for insurance broker fees4425
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00580098
Policy instance 1
Insurance contract or identification number00580098
Number of Individuals Covered250
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,903
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $117,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,903
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282782
Policy instance 2
Insurance contract or identification number282782
Number of Individuals Covered87
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $37,119
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $691,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,119
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 3
Insurance contract or identification number602917
Number of Individuals Covered75
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $19,732
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $411,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,732
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 4
Insurance contract or identification number269718
Number of Individuals Covered132
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $23,651
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $433,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,651
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 2
Insurance contract or identification number602917
Number of Individuals Covered77
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $22,751
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $445,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,751
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0624917
Policy instance 1
Insurance contract or identification number0624917
Number of Individuals Covered255
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,221
Total amount of fees paid to insurance companyUSD $738
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,221
Amount paid for insurance broker fees738
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 3
Insurance contract or identification number269718
Number of Individuals Covered129
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $23,612
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $478,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,612
Insurance broker organization code?3
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number282782
Policy instance 4
Insurance contract or identification number282782
Number of Individuals Covered104
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $37,102
Total amount of fees paid to insurance companyUSD $4,465
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $847,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,102
Amount paid for insurance broker fees4465
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00624917
Policy instance 1
Insurance contract or identification number00624917
Number of Individuals Covered95
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $30,405
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $154,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,405
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 2
Insurance contract or identification number269718
Number of Individuals Covered109
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $21,587
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $435,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,587
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 3
Insurance contract or identification number602917
Number of Individuals Covered97
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $25,388
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $505,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,388
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number0624917
Policy instance 4
Insurance contract or identification number0624917
Number of Individuals Covered210
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,751
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $89,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,751
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 1
Insurance contract or identification number269718
Number of Individuals Covered89
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $14,503
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $304,085
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,382
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 2
Insurance contract or identification number602917
Number of Individuals Covered115
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $27,288
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $548,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,014
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered199
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,616
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $90,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,350
Insurance broker organization code?3
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number277290
Policy instance 4
Insurance contract or identification number277290
Number of Individuals Covered97
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $32,420
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $666,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,420
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 2
Insurance contract or identification number602917
Number of Individuals Covered136
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $22,624
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,624
Insurance broker organization code?3
Insurance broker nameJTW & ASSOCIATES INC
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number277290
Policy instance 4
Insurance contract or identification number277290
Number of Individuals Covered73
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $27,634
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,633
Insurance broker organization code?3
Insurance broker nameJTW & ASSOCIATES INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 1
Insurance contract or identification number269718
Number of Individuals Covered68
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $11,094
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,094
Insurance broker organization code?3
Insurance broker nameJTW & ASSOCIATES INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered254
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,439
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,446
Insurance broker organization code?3
Insurance broker nameUSI OF SOUTHERN CALIFORNIA INS SVCS
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number277290
Policy instance 4
Insurance contract or identification number277290
Number of Individuals Covered106
Insurance policy start date2015-08-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,570
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $261,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,570
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered295
Insurance policy start date2015-07-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,880
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,880
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number277290
Policy instance 2
Insurance contract or identification number277290
Number of Individuals Covered117
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $23,417
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $538,607
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,189
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718/602917
Policy instance 1
Insurance contract or identification number269718/602917
Number of Individuals Covered188
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $29,936
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $602,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,503
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered269
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $3,738
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $61,524
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,284
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number277290
Policy instance 2
Insurance contract or identification number277290
Number of Individuals Covered99
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $17,512
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $469,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,512
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718/602917
Policy instance 1
Insurance contract or identification number269718/602917
Number of Individuals Covered144
Insurance policy start date2014-07-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $14,193
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $278,443
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,193
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES, INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number2777290
Policy instance 3
Insurance contract or identification number2777290
Number of Individuals Covered94
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $17,017
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $424,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,017
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 1
Insurance contract or identification number269718
Number of Individuals Covered64
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $11,503
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $174,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $11,503
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 5
Insurance contract or identification number307452
Number of Individuals Covered65
Insurance policy start date2013-10-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $1,007
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,007
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 4
Insurance contract or identification number602917
Number of Individuals Covered84
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $15,002
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $325,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $15,002
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES, INC.
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number277290
Policy instance 3
Insurance contract or identification number277290
Number of Individuals Covered94
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $17,014
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $424,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5387644
Policy instance 2
Insurance contract or identification number5387644
Number of Individuals Covered85
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $2,117
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Commission paid to Insurance BrokerUSD $2,117
Insurance broker organization code?3
Insurance broker nameJTW AND ASSOCIATES
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5387644
Policy instance 2
Insurance contract or identification number5387644
Number of Individuals Covered85
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $1,365
Total amount of fees paid to insurance companyUSD $204
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $219
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUNITED AGENCIES, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 1
Insurance contract or identification number269718
Number of Individuals Covered54
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $9,540
Welfare Benefit Premiums Paid to CarrierUSD $151,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,204
Insurance broker organization code?3
Insurance broker nameSTEPHEN HAMMITT
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered53
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $19,378
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $376,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,378
Insurance broker organization code?3
Insurance broker nameUNITED AGENCIES
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 4
Insurance contract or identification number602917
Number of Individuals Covered84
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $13,093
Welfare Benefit Premiums Paid to CarrierUSD $261,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,101
Insurance broker organization code?3
Insurance broker nameCENTENNIAL GROUP BENEFITS AND INSUR
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5387644
Policy instance 3
Insurance contract or identification number5387644
Number of Individuals Covered194
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $4,192
Total amount of fees paid to insurance companyUSD $705
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917/269718
Policy instance 2
Insurance contract or identification number602917/269718
Number of Individuals Covered119
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $36,748
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $557,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 1
Insurance contract or identification number307452
Number of Individuals Covered154
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $34,308
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $668,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917/269718
Policy instance 3
Insurance contract or identification number602917/269718
Number of Individuals Covered294
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $49,422
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $866,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 2
Insurance contract or identification numberKM05589593
Number of Individuals Covered188
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $520
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,428
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 1
Insurance contract or identification number307452
Number of Individuals Covered217
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $33,616
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $671,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5387644
Policy instance 4
Insurance contract or identification number5387644
Number of Individuals Covered211
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $4,285
Total amount of fees paid to insurance companyUSD $61
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 4
Insurance contract or identification number307452
Number of Individuals Covered201
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $33,050
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $539,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,438
Insurance broker organization code?3
Insurance broker nameUNITED AGENCIES, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 2
Insurance contract or identification numberKM05589593
Number of Individuals Covered225
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $2,363
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $58,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,363
Insurance broker organization code?3
Insurance broker nameCENTENNIAL GROUP BENEFITS & INSURAN
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number602917
Policy instance 6
Insurance contract or identification number602917
Number of Individuals Covered130
Insurance policy start date2009-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $31,299
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $581,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,814
Insurance broker organization code?3
Insurance broker nameUNITED AGENCIES, INC.
COPOWER/VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number40569
Policy instance 1
Insurance contract or identification number40569
Number of Individuals Covered50
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of fees paid to insurance companyUSD $427
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees427
Insurance broker organization code?3
Insurance broker nameCENTENNIAL GROUP BENEFITS & INSURAN
UDC DENTAL OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 52031 )
Policy contract number5387644
Policy instance 3
Insurance contract or identification number5387644
Number of Individuals Covered188
Insurance policy start date2008-10-01
Insurance policy end date2009-09-30
Total amount of commissions paid to insurance brokerUSD $3,279
Total amount of fees paid to insurance companyUSD $271
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $32,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,279
Amount paid for insurance broker fees271
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameCENTENNIAL GROUP BENEFITS & INSURAN
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 5
Insurance contract or identification number269718
Number of Individuals Covered54
Insurance policy start date2000-04-01
Insurance policy end date2010-03-31
Total amount of commissions paid to insurance brokerUSD $16,273
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $201,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,311
Insurance broker organization code?3
Insurance broker nameUNITED AGENCIES, INC.
KAISER FOUNDATION HEALTH PLANS INC. (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number602917
Policy instance 5
Insurance contract or identification number602917
Number of Individuals Covered107
Insurance policy start date2008-10-01
Insurance policy end date2009-03-31
Total amount of commissions paid to insurance brokerUSD $14,405
Total amount of fees paid to insurance companyUSD $7,500
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $373,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,405
Amount paid for insurance broker fees7500
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameCENTENNIAL GROUP BENEFITS & INSURAN
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered183
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $19,782
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $385,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,812
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 2
Insurance contract or identification numberKM05589593
Number of Individuals Covered217
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $2,614
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $43,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,545
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
COPOWER/VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number40569
Policy instance 1
Insurance contract or identification number40569
Number of Individuals Covered47
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $707
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $189
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 4
Insurance contract or identification number269718
Number of Individuals Covered50
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $8,668
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $116,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,389
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 2
Insurance contract or identification numberKM05589593
Number of Individuals Covered122
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $1,872
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,872
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 3
Insurance contract or identification number269718
Number of Individuals Covered39
Insurance policy start date2007-04-01
Insurance policy end date2008-03-31
Total amount of commissions paid to insurance brokerUSD $2,137
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,137
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 4
Insurance contract or identification number307452
Number of Individuals Covered95
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $14,364
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $221,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,364
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
COPOWER/VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number40569
Policy instance 1
Insurance contract or identification number40569
Number of Individuals Covered6
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $154
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $154
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 4
Insurance contract or identification number269718
Number of Individuals Covered6
Insurance policy start date2006-04-01
Insurance policy end date2007-03-31
Total amount of commissions paid to insurance brokerUSD $1,334
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,334
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
COPOWER/VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number40569
Policy instance 1
Insurance contract or identification number40569
Number of Individuals Covered2
Insurance policy start date2006-01-01
Insurance policy end date2006-12-31
Total amount of commissions paid to insurance brokerUSD $63
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 2
Insurance contract or identification numberKM05589593
Number of Individuals Covered125
Insurance policy start date2006-01-01
Insurance policy end date2006-12-31
Total amount of commissions paid to insurance brokerUSD $1,526
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $26,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,526
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 3
Insurance contract or identification number307452
Number of Individuals Covered97
Total amount of commissions paid to insurance brokerUSD $13,209
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $173,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,209
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05589593
Policy instance 1
Insurance contract or identification numberKM05589593
Number of Individuals Covered82
Insurance policy start date2005-07-01
Insurance policy end date2006-06-30
Total amount of commissions paid to insurance brokerUSD $1,001
Dental Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $10,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,001
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number307452
Policy instance 2
Insurance contract or identification number307452
Number of Individuals Covered59
Insurance policy start date2005-07-01
Insurance policy end date2005-12-31
Total amount of commissions paid to insurance brokerUSD $4,914
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $62,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,914
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number269718
Policy instance 3
Insurance contract or identification number269718
Number of Individuals Covered5
Insurance policy start date2005-04-01
Insurance policy end date2006-03-31
Total amount of commissions paid to insurance brokerUSD $1,499
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,499
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT
COPOWER/VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number40569
Policy instance 4
Insurance contract or identification number40569
Number of Individuals Covered5
Insurance policy start date2005-04-01
Insurance policy end date2005-12-31
Total amount of commissions paid to insurance brokerUSD $77
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $770
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77
Insurance broker organization code?3
Insurance broker nameSTEPHEN F HAMMITT

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