401k Plan data: CCM CORPORATION INSURANCE BENEFIT PLAN plan

CCM CORPORATION INSURANCE BENEFIT PLAN 401k Plan overview

Plan Name	CCM CORPORATION INSURANCE BENEFIT PLAN
Plan identification number	501

CCM CORPORATION INSURANCE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

CCM CORPORATION has sponsored the creation of one or more 401k plans.

Company Name: CCM CORPORATION

Employer identification number (EIN): 446013075

NAIC Classification: 444110
NAIC Description: Home Centers

Additional information about CCM CORPORATION

Jurisdiction of Incorporation: Colorado Department of State

Incorporation Date: 2003-02-14

Company Identification Number: 20031051271

Legal Registered Office Address: 4450 ARAPAHOE #100

Boulder
United States of America (USA)
80303

More information about CCM CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CCM CORPORATION INSURANCE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-01-01
501 2018-01-01
501 2017-01-01 WILLIAM C. MEEK
501 2016-01-01 WILLIAM C. MEEK
501 2015-01-01 WILLIAM C. MEEK
501 2014-01-01 WILLIAM C. MEEK
501 2013-01-01 WILLIAM C. MEEK
501 2012-01-01 WILLIAM C. MEEK
501 2011-01-01 WILLIAM C MEEK

Plan Statistics for CCM CORPORATION INSURANCE BENEFIT PLAN

401k plan membership statisitcs for CCM CORPORATION INSURANCE BENEFIT PLAN

Measure Date Value
2018: CCM CORPORATION INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 301
Number of retired or separated participants receiving benefits 2018-01-01 7
Number of other retired or separated participants entitled to future benefits 2018-01-01 0
Total of all active and inactive participants 2018-01-01 308
2017: CCM CORPORATION INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 194
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 194
Total of all active and inactive participants 2017-01-01 194
Total participants 2017-01-01 194
2016: CCM CORPORATION INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 333
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 194
Total of all active and inactive participants 2016-01-01 194
Total participants 2016-01-01 194
2015: CCM CORPORATION INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 333
Total of all active and inactive participants 2015-01-01 333
Total participants 2015-01-01 0
2014: CCM CORPORATION INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 299
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 299
Total of all active and inactive participants 2014-01-01 299
Total participants 2014-01-01 0
2013: CCM CORPORATION INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 267
Total of all active and inactive participants 2013-01-01 267
Total participants 2013-01-01 0
2012: CCM CORPORATION INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 241
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 245
Total of all active and inactive participants 2012-01-01 245
Total participants 2012-01-01 0
2011: CCM CORPORATION INSURANCE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 244
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 244
Total of all active and inactive participants 2011-01-01 244
Total participants 2011-01-01 244

Measure	Date	Value
2018: CCM CORPORATION INSURANCE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	301
Number of retired or separated participants receiving benefits	2018-01-01	7
Number of other retired or separated participants entitled to future benefits	2018-01-01	0
Total of all active and inactive participants	2018-01-01	308
2017: CCM CORPORATION INSURANCE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	194
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	194
Total of all active and inactive participants	2017-01-01	194
Total participants	2017-01-01	194
2016: CCM CORPORATION INSURANCE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	333
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	194
Total of all active and inactive participants	2016-01-01	194
Total participants	2016-01-01	194
2015: CCM CORPORATION INSURANCE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	333
Total of all active and inactive participants	2015-01-01	333
Total participants	2015-01-01	0
2014: CCM CORPORATION INSURANCE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	299
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	299
Total of all active and inactive participants	2014-01-01	299
Total participants	2014-01-01	0
2013: CCM CORPORATION INSURANCE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	267
Total of all active and inactive participants	2013-01-01	267
Total participants	2013-01-01	0
2012: CCM CORPORATION INSURANCE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	241
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	245
Total of all active and inactive participants	2012-01-01	245
Total participants	2012-01-01	0
2011: CCM CORPORATION INSURANCE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	244
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	244
Total of all active and inactive participants	2011-01-01	244
Total participants	2011-01-01	244

Form 5500 Responses for CCM CORPORATION INSURANCE BENEFIT PLAN

2018: CCM CORPORATION INSURANCE BENEFIT PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: CCM CORPORATION INSURANCE BENEFIT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: CCM CORPORATION INSURANCE BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CCM CORPORATION INSURANCE BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: CCM CORPORATION INSURANCE BENEFIT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: CCM CORPORATION INSURANCE BENEFIT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: CCM CORPORATION INSURANCE BENEFIT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: CCM CORPORATION INSURANCE BENEFIT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	301
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $644
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $6,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $644
Insurance broker organization code?	3

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	79
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,359
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $387,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,687
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	301
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,061
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $30,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,061
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0063546

Policy instance

Insurance contract or identification number	W0063546
Number of Individuals Covered	256
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $81,126
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $1,622,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $81,126
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	98
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,178
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $41,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,178
Insurance broker organization code?	3

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	83
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $9,067
Welfare Benefit Premiums Paid to Carrier	USD $414,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,067
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0063546

Policy instance

Insurance contract or identification number	W0063546
Number of Individuals Covered	178
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $78,264
Welfare Benefit Premiums Paid to Carrier	USD $1,565,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $78,264
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	312
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $660
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $6,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $660
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	312
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $3,116
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,116
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	98
Insurance policy start date	2017-01-01
Insurance policy end date	2018-01-01
Total amount of commissions paid to insurance broker	USD $5,241
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,241
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	105
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $8,776
Welfare Benefit Premiums Paid to Carrier	USD $401,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,776
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276914

Policy instance

Insurance contract or identification number	276914
Number of Individuals Covered	165
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $54,561
Welfare Benefit Premiums Paid to Carrier	USD $1,363,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $54,561
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	333
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $630
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $6,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $630
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	88
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,531
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,531
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MES VISION (National Association of Insurance Commissioners NAIC id number: 62111 )

Policy contract number

2013-003

Policy instance

Insurance contract or identification number	2013-003
Number of Individuals Covered	216
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,424
Total amount of fees paid to insurance company	USD $4,843
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,424
Amount paid for insurance broker fees	4843
Additional information about fees paid to insurance broker	ADMIN FEES
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

K1900885

Policy instance

Insurance contract or identification number	K1900885
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,389
Total amount of fees paid to insurance company	USD $9,326
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $4,389
Amount paid for insurance broker fees	9326
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	323
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,895
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,895
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	81
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,479
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,479
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

K1900885

Policy instance

Insurance contract or identification number	K1900885
Number of Individuals Covered	228
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,176
Total amount of fees paid to insurance company	USD $8,874
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $4,176
Amount paid for insurance broker fees	8874
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MES VISION (National Association of Insurance Commissioners NAIC id number: 62111 )

Policy contract number

2013-003

Policy instance

Insurance contract or identification number	2013-003
Number of Individuals Covered	210
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,245
Total amount of fees paid to insurance company	USD $4,234
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,245
Amount paid for insurance broker fees	4234
Additional information about fees paid to insurance broker	ADMIN FEES
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	299
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $578
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $5,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $578
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	299
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $2,647
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,647
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276914

Policy instance

Insurance contract or identification number	276914
Number of Individuals Covered	161
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $49,266
Welfare Benefit Premiums Paid to Carrier	USD $1,245,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,266
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	105
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,264
Welfare Benefit Premiums Paid to Carrier	USD $454,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,264
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	97
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-13
Total amount of commissions paid to insurance broker	USD $8,105
Welfare Benefit Premiums Paid to Carrier	USD $367,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,105
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	267
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $507
Total amount of fees paid to insurance company	USD $111
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD & D
Welfare Benefit Premiums Paid to Carrier	USD $5,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $507
Amount paid for insurance broker fees	111
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	267
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,408
Total amount of fees paid to insurance company	USD $544
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,408
Amount paid for insurance broker fees	544
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

276914

Policy instance

Insurance contract or identification number	276914
Number of Individuals Covered	192
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $42,900
Welfare Benefit Premiums Paid to Carrier	USD $1,060,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,900
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	73
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,245
Total amount of fees paid to insurance company	USD $1,414
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,245
Amount paid for insurance broker fees	1414
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MES VISION (National Association of Insurance Commissioners NAIC id number: 62111 )

Policy contract number

2013-003

Policy instance

Insurance contract or identification number	2013-003
Number of Individuals Covered	173
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,058
Total amount of fees paid to insurance company	USD $4,251
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,058
Amount paid for insurance broker fees	4251
Additional information about fees paid to insurance broker	ADMIN FEES
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

K1900885

Policy instance

Insurance contract or identification number	K1900885
Number of Individuals Covered	187
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,656
Total amount of fees paid to insurance company	USD $7,769
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,656
Amount paid for insurance broker fees	7769
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

PW589

Policy instance

Insurance contract or identification number	PW589
Number of Individuals Covered	169
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,022
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,022
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

922

Policy instance

Insurance contract or identification number	922
Number of Individuals Covered	355
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,890
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,890
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	90
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-13
Total amount of commissions paid to insurance broker	USD $7,352
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $281,995
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,352
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

Policy instance

Number of Individuals Covered	125
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $43,873
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $884,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,873
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AKBA

Policy instance

Insurance contract or identification number	GLTD0AKBA
Number of Individuals Covered	245
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,356
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,356
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AKBA

Policy instance

Insurance contract or identification number	GLUG0AKBA
Number of Individuals Covered	245
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $484
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $484
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0AKBA

Policy instance

Insurance contract or identification number	GVTL0AKBA
Number of Individuals Covered	72
Total amount of commissions paid to insurance broker	USD $5,566
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,566
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

PW589

Policy instance

Insurance contract or identification number	PW589
Number of Individuals Covered	169
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,126
Total amount of fees paid to insurance company	USD $328
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	97
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-13
Total amount of commissions paid to insurance broker	USD $7,484
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $323,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

694984G

Policy instance

Insurance contract or identification number	694984G
Number of Individuals Covered	244
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $9,340
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $86,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

921047-49

Policy instance

Insurance contract or identification number	921047-49
Number of Individuals Covered	219
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $45,569
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $882,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

BN2259

Policy instance

Insurance contract or identification number	BN2259
Number of Individuals Covered	4
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,624
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,063
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

922

Policy instance

Insurance contract or identification number	922
Number of Individuals Covered	350
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,323
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

BN2259

Policy instance

Insurance contract or identification number	BN2259
Number of Individuals Covered	6
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $863
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $191
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

921047-49

Policy instance

Insurance contract or identification number	921047-49
Number of Individuals Covered	419
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $51,999
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,039,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51,999
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

694984G

Policy instance

Insurance contract or identification number	694984G
Number of Individuals Covered	247
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $9,640
Total amount of fees paid to insurance company	USD $1,429
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $105,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,640
Amount paid for insurance broker fees	1429
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

922

Policy instance

Insurance contract or identification number	922
Number of Individuals Covered	398
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,614
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $11,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,614
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

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

Policy contract number

33247

Policy instance

Insurance contract or identification number	33247
Number of Individuals Covered	133
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-13
Total amount of commissions paid to insurance broker	USD $6,781
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $315,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,781
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

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

Policy contract number

PW589

Policy instance

Insurance contract or identification number	PW589
Number of Individuals Covered	177
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,448
Total amount of fees paid to insurance company	USD $328
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,206
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,448
Amount paid for insurance broker fees	328
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

G0360

Policy instance

Insurance contract or identification number	G0360
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $2,629
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,629
Insurance broker organization code?	3
Insurance broker name	GFBB BENEFITS & INSURANCE SERVICES,

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Company Name:	CCM CORPORATION
Employer identification number (EIN):	446013075
NAIC Classification:	444110
NAIC Description:	Home Centers

Jurisdiction of Incorporation:	Colorado Department of State
Incorporation Date:	2003-02-14
Company Identification Number:	20031051271
Legal Registered Office Address:	4450 ARAPAHOE #100 Boulder United States of America (USA) 80303