401k Plan data: XYLEM CORPORATE WELFARE PLAN plan

XYLEM CORPORATE WELFARE PLAN 401k Plan overview

Plan Name	XYLEM CORPORATE WELFARE PLAN
Plan identification number	501

XYLEM CORPORATE WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Prepaid legal Long-term disability cover Severance pay Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

XYLEM INC. has sponsored the creation of one or more 401k plans.

Company Name: XYLEM INC.

Employer identification number (EIN): 452080495

NAIC Classification: 333200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan XYLEM CORPORATE WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 TARANDA M. FROST 2023-10-11
501 2021-01-01 TARANDA M FROST 2022-10-12
501 2020-01-01 SHIRLEY CHEN 2021-10-12
501 2019-01-01 SHIRLEY CHEN 2020-09-01
501 2018-01-01 RHONDA MCKEEVER 2019-09-20
501 2017-01-01 RHONDA MCKEEVER
501 2016-01-01 RHONDA MCKEEVER
501 2015-01-01 RHONDA MCKEEVER
501 2014-01-01 RHONDA MCKEEVER
501 2013-01-01 RHONDA MCKEEVER
501 2012-01-01 RHONDA MCKEEVER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2022-01-01	TARANDA M. FROST	2023-10-11
501	2021-01-01	TARANDA M FROST	2022-10-12
501	2020-01-01	SHIRLEY CHEN	2021-10-12
501	2019-01-01	SHIRLEY CHEN	2020-09-01
501	2018-01-01	RHONDA MCKEEVER	2019-09-20
501	2017-01-01	RHONDA MCKEEVER
501	2016-01-01	RHONDA MCKEEVER
501	2015-01-01	RHONDA MCKEEVER
501	2014-01-01	RHONDA MCKEEVER
501	2013-01-01	RHONDA MCKEEVER
501	2012-01-01	RHONDA MCKEEVER

Plan Statistics for XYLEM CORPORATE WELFARE PLAN

401k plan membership statisitcs for XYLEM CORPORATE WELFARE PLAN

Measure Date Value
2022: XYLEM CORPORATE WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 5,666
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 5,795
Number of retired or separated participants receiving benefits 2022-01-01 60
Number of other retired or separated participants entitled to future benefits 2022-01-01 287
Total of all active and inactive participants 2022-01-01 6,142
Number of employers contributing to the scheme 2022-01-01 0
2021: XYLEM CORPORATE WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 5,698
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 5,509
Number of retired or separated participants receiving benefits 2021-01-01 63
Number of other retired or separated participants entitled to future benefits 2021-01-01 94
Total of all active and inactive participants 2021-01-01 5,666
Number of employers contributing to the scheme 2021-01-01 0
2020: XYLEM CORPORATE WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 5,816
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 5,590
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 108
Total of all active and inactive participants 2020-01-01 5,698
Number of employers contributing to the scheme 2020-01-01 0
2019: XYLEM CORPORATE WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 5,545
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 5,580
Number of retired or separated participants receiving benefits 2019-01-01 236
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 5,816
Number of employers contributing to the scheme 2019-01-01 0
2018: XYLEM CORPORATE WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 5,516
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 5,545
Number of retired or separated participants receiving benefits 2018-01-01 193
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 5,738
Number of employers contributing to the scheme 2018-01-01 0
2017: XYLEM CORPORATE WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 3,833
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 3,876
Number of retired or separated participants receiving benefits 2017-01-01 165
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 4,041
2016: XYLEM CORPORATE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 3,158
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 3,677
Number of retired or separated participants receiving benefits 2016-01-01 156
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 3,833
2015: XYLEM CORPORATE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 3,017
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 3,002
Number of retired or separated participants receiving benefits 2015-01-01 156
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 3,158
2014: XYLEM CORPORATE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 3,270
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 2,957
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 2,957
2013: XYLEM CORPORATE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 2,710
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 3,260
Number of retired or separated participants receiving benefits 2013-01-01 10
Total of all active and inactive participants 2013-01-01 3,270
2012: XYLEM CORPORATE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 2,727
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 2,710
Number of retired or separated participants receiving benefits 2012-01-01 13
Total of all active and inactive participants 2012-01-01 2,723

Measure	Date	Value
2022: XYLEM CORPORATE WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	5,666
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	5,795
Number of retired or separated participants receiving benefits	2022-01-01	60
Number of other retired or separated participants entitled to future benefits	2022-01-01	287
Total of all active and inactive participants	2022-01-01	6,142
Number of employers contributing to the scheme	2022-01-01	0
2021: XYLEM CORPORATE WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	5,698
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	5,509
Number of retired or separated participants receiving benefits	2021-01-01	63
Number of other retired or separated participants entitled to future benefits	2021-01-01	94
Total of all active and inactive participants	2021-01-01	5,666
Number of employers contributing to the scheme	2021-01-01	0
2020: XYLEM CORPORATE WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	5,816
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	5,590
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	108
Total of all active and inactive participants	2020-01-01	5,698
Number of employers contributing to the scheme	2020-01-01	0
2019: XYLEM CORPORATE WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	5,545
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	5,580
Number of retired or separated participants receiving benefits	2019-01-01	236
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	5,816
Number of employers contributing to the scheme	2019-01-01	0
2018: XYLEM CORPORATE WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	5,516
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	5,545
Number of retired or separated participants receiving benefits	2018-01-01	193
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	5,738
Number of employers contributing to the scheme	2018-01-01	0
2017: XYLEM CORPORATE WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	3,833
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	3,876
Number of retired or separated participants receiving benefits	2017-01-01	165
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	4,041
2016: XYLEM CORPORATE WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	3,158
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	3,677
Number of retired or separated participants receiving benefits	2016-01-01	156
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	3,833
2015: XYLEM CORPORATE WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	3,017
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	3,002
Number of retired or separated participants receiving benefits	2015-01-01	156
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	3,158
2014: XYLEM CORPORATE WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	3,270
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	2,957
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	2,957
2013: XYLEM CORPORATE WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	2,710
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	3,260
Number of retired or separated participants receiving benefits	2013-01-01	10
Total of all active and inactive participants	2013-01-01	3,270
2012: XYLEM CORPORATE WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	2,727
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	2,710
Number of retired or separated participants receiving benefits	2012-01-01	13
Total of all active and inactive participants	2012-01-01	2,723

Form 5500 Responses for XYLEM CORPORATE WELFARE PLAN

2022: XYLEM CORPORATE WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: XYLEM CORPORATE WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: XYLEM CORPORATE WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: XYLEM CORPORATE WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: XYLEM CORPORATE WELFARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
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: XYLEM CORPORATE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: XYLEM CORPORATE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: XYLEM CORPORATE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: XYLEM CORPORATE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: XYLEM CORPORATE WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: XYLEM CORPORATE WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

5434

Policy instance

Insurance contract or identification number	5434
Number of Individuals Covered	2
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,486
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

681007G

Policy instance

Insurance contract or identification number	681007G
Number of Individuals Covered	5795
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $121,406
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,491,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	121406
Additional information about fees paid to insurance broker	FEES, BONUS
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

876001

Policy instance

Insurance contract or identification number	876001
Number of Individuals Covered	551
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

416724

Policy instance

Insurance contract or identification number	416724
Number of Individuals Covered	212
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $36,117
Total amount of fees paid to insurance company	USD $0
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 $36,117
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090223

Policy instance

Insurance contract or identification number	6090223
Number of Individuals Covered	709
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $15,682
Total amount of fees paid to insurance company	USD $87
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $157,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,682
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADDN10892612

Policy instance

Insurance contract or identification number	ADDN10892612
Number of Individuals Covered	5795
Insurance policy start date	2021-10-31
Insurance policy end date	2022-10-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $42,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97323551001

Policy instance

Insurance contract or identification number	97323551001
Number of Individuals Covered	7975
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $679,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

010026

Policy instance

Insurance contract or identification number	010026
Number of Individuals Covered	449
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,259
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,763,899
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	4259
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS AND NON-MONETARY COMPENSATION
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

802782

Policy instance

Insurance contract or identification number	802782
Number of Individuals Covered	3575
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $174,052
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $1,147,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $174,052
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

206

Policy instance

Insurance contract or identification number	206
Number of Individuals Covered	5795
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $50,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

45251

Policy instance

Insurance contract or identification number	45251
Number of Individuals Covered	549
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $131,362
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $717,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $131,362
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	115
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $590,253
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 number

222998

Policy instance

Insurance contract or identification number	222998
Number of Individuals Covered	9329
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $198,892
Total amount of fees paid to insurance company	USD $37,471
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,632,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $161,248
Amount paid for insurance broker fees	33804
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

010026

Policy instance

Insurance contract or identification number	010026
Number of Individuals Covered	478
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,459
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,771,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	4459
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS AND NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

5434

Policy instance

Insurance contract or identification number	5434
Number of Individuals Covered	2
Insurance policy start date	2020-08-01
Insurance policy end date	2021-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADDN10892612

Policy instance

Insurance contract or identification number	ADDN10892612
Number of Individuals Covered	4551
Insurance policy start date	2020-10-31
Insurance policy end date	2021-10-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $42,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090223

Policy instance

Insurance contract or identification number	6090223
Number of Individuals Covered	738
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $15,912
Total amount of fees paid to insurance company	USD $142
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $145,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,912
Amount paid for insurance broker fees	71
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

416724

Policy instance

Insurance contract or identification number	416724
Number of Individuals Covered	226
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $31,974
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,974
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

876001

Policy instance

Insurance contract or identification number	876001
Number of Individuals Covered	554
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $191,264
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

681007G

Policy instance

Insurance contract or identification number	681007G
Number of Individuals Covered	5852
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,834,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

23735

Policy instance

Insurance contract or identification number	23735
Number of Individuals Covered	3729
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $168,159
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $850,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $168,159
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

206

Policy instance

Insurance contract or identification number	206
Number of Individuals Covered	4551
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $75,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97323551001

Policy instance

Insurance contract or identification number	97323551001
Number of Individuals Covered	448
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $22,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )

Policy contract number

98230221001

Policy instance

Insurance contract or identification number	98230221001
Number of Individuals Covered	7311
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $586,216
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

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	129
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $811,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

45251

Policy instance

Insurance contract or identification number	45251
Number of Individuals Covered	547
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $129,837
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $712,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $129,837
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

200994

Policy instance

Insurance contract or identification number	200994
Number of Individuals Covered	9189
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $160,878
Total amount of fees paid to insurance company	USD $26,309
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,139,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $121,041
Amount paid for insurance broker fees	23677
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

207

Policy instance

Insurance contract or identification number	207
Number of Individuals Covered	215
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $2,405
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

5434

Policy instance

Insurance contract or identification number	5434
Number of Individuals Covered	2
Insurance policy start date	2021-08-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

416724

Policy instance

Insurance contract or identification number	416724
Number of Individuals Covered	253
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $35,805
Total amount of fees paid to insurance company	USD $0
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 $35,805
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

97323551001

Policy instance

Insurance contract or identification number	97323551001
Number of Individuals Covered	8029
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $693,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

876001

Policy instance

Insurance contract or identification number	876001
Number of Individuals Covered	586
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $217,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

55244

Policy instance

Insurance contract or identification number	55244
Number of Individuals Covered	169
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,801
Total amount of fees paid to insurance company	USD $0
Dental 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 $7,801
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

681007G

Policy instance

Insurance contract or identification number	681007G
Number of Individuals Covered	5590
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $67,614
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,388,973
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	67614
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

45251

Policy instance

Insurance contract or identification number	45251
Number of Individuals Covered	189
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $87,433
Total amount of fees paid to insurance company	USD $0
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 $87,433
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090223

Policy instance

Insurance contract or identification number	6090223
Number of Individuals Covered	662
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,897
Total amount of fees paid to insurance company	USD $52
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $148,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,897
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADDN10892612

Policy instance

Insurance contract or identification number	ADDN10892612
Number of Individuals Covered	5590
Insurance policy start date	2019-10-31
Insurance policy end date	2020-10-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $42,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

5434

Policy instance

Insurance contract or identification number	5434
Number of Individuals Covered	2
Insurance policy start date	2019-08-01
Insurance policy end date	2020-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,972
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

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	130
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $750,556
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 number

200994

Policy instance

Insurance contract or identification number	200994
Number of Individuals Covered	9397
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $210,384
Total amount of fees paid to insurance company	USD $35,986
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $5,494,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $165,401
Amount paid for insurance broker fees	32522
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

206

Policy instance

Insurance contract or identification number	206
Number of Individuals Covered	5590
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $58,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HEALTH AND HUMAN RESOURCES CENTER, INC. (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

207

Policy instance

Insurance contract or identification number	207
Number of Individuals Covered	225
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $2,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

23735

Policy instance

Insurance contract or identification number	23735
Number of Individuals Covered	3621
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $158,768
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $1,010,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $158,768
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

010026

Policy instance

Insurance contract or identification number	010026
Number of Individuals Covered	502
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $4,935
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,123,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4935
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADDN10892612

Policy instance

Insurance contract or identification number	ADDN10892612
Number of Individuals Covered	5590
Insurance policy start date	2018-10-31
Insurance policy end date	2019-10-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	BUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $42,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090223

Policy instance

Insurance contract or identification number	6090223
Number of Individuals Covered	625
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,912
Total amount of fees paid to insurance company	USD $73
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $139,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,912
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSAITON

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

416724

Policy instance

Insurance contract or identification number	416724
Number of Individuals Covered	268
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $47,674
Total amount of fees paid to insurance company	USD $0
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 $36,870
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

876001

Policy instance

Insurance contract or identification number	876001
Number of Individuals Covered	600
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $167
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $243,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	167
Additional information about fees paid to insurance broker	INDIRECT COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

681007G

Policy instance

Insurance contract or identification number	681007G
Number of Individuals Covered	5798
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $61,544
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,253,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	61544
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

EMPLOYEE NETWORK INC. (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

XYL7422

Policy instance

Insurance contract or identification number	XYL7422
Number of Individuals Covered	5370
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $64,440
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

5434

Policy instance

Insurance contract or identification number	5434
Number of Individuals Covered	2
Insurance policy start date	2018-08-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

010026

Policy instance

Insurance contract or identification number	010026
Number of Individuals Covered	518
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $5,212
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,506,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	5212
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

500106

Policy instance

Insurance contract or identification number	500106
Number of Individuals Covered	591
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $125,464
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $773,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $125,464
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

98454391001

Policy instance

Insurance contract or identification number	98454391001
Number of Individuals Covered	513
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $26,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

FIDELITY SECURITY LIFE INSURANCE COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 67288 )

Policy contract number

98230221001

Policy instance

Insurance contract or identification number	98230221001
Number of Individuals Covered	7585
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $717,140
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 number

200994

Policy instance

Insurance contract or identification number	200994
Number of Individuals Covered	4756
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $206,308
Total amount of fees paid to insurance company	USD $14,145
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,913,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $159,359
Amount paid for insurance broker fees	10710
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION MARKETING FEES NON-MONETARY COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	124
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $758,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00500106

Policy instance

Insurance contract or identification number	00500106
Number of Individuals Covered	63
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $545,078
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

ADD N10892612

Policy instance

Insurance contract or identification number	ADD N10892612
Number of Individuals Covered	5614
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Other welfare benefits provided	BTA
Welfare Benefit Premiums Paid to Carrier	USD $41,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BERKLEY LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64890 )

Policy contract number

ERL L 16100825

Policy instance

Insurance contract or identification number	ERL L 16100825
Number of Individuals Covered	2600
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $62,601
Welfare Benefit Premiums Paid to Carrier	USD $1,252,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	62601
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

HYATT LEGAL PLANS (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

6090223

Policy instance

Insurance contract or identification number	6090223
Number of Individuals Covered	314
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $7,182
Other welfare benefits provided	LEGAL
Welfare Benefit Premiums Paid to Carrier	USD $71,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,182
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9866328

Policy instance

Insurance contract or identification number	9866328
Number of Individuals Covered	83
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,979
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00416724

Policy instance

Insurance contract or identification number	00416724
Number of Individuals Covered	293
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $52,246
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 $52,246
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFIT CONCEPTS, INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B&H10027,PC2067

Policy instance

Insurance contract or identification number	B&H10027,PC2067
Number of Individuals Covered	599
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $4,723
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,828,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	4723
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9748609

Policy instance

Insurance contract or identification number	9748609
Number of Individuals Covered	13
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9823022

Policy instance

Insurance contract or identification number	9823022
Number of Individuals Covered	4018
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $268,683
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

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	40
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $189,689
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

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	10
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $76,746
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 number

0096482

Policy instance

Insurance contract or identification number	0096482
Number of Individuals Covered	1108
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP UNIVERSAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $675,260
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

PAI 0009135396

Policy instance

Insurance contract or identification number	PAI 0009135396
Number of Individuals Covered	1725
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $33,728
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $224,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,728
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC.

EMPLOYEE NETWORK INC. (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

XYL7422

Policy instance

Insurance contract or identification number	XYL7422
Number of Individuals Covered	3471
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $41,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00045251

Policy instance

Insurance contract or identification number	00045251
Number of Individuals Covered	197
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $93,066
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 $93,066
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00518497

Policy instance

Insurance contract or identification number	00518497
Number of Individuals Covered	73
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $172,619
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9732355

Policy instance

Insurance contract or identification number	9732355
Number of Individuals Covered	534
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9845439

Policy instance

Insurance contract or identification number	9845439
Number of Individuals Covered	53
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0876001

Policy instance

Insurance contract or identification number	0876001
Number of Individuals Covered	659
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $277,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

32588

Policy instance

Insurance contract or identification number	32588
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 $6,559
Dental 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 $6,559
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

681007G

Policy instance

Insurance contract or identification number	681007G
Number of Individuals Covered	3922
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of fees paid to insurance company	USD $83,860
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $1,231,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	83860
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00518497

Policy instance

Insurance contract or identification number	00518497
Number of Individuals Covered	86
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00045251

Policy instance

Insurance contract or identification number	00045251
Number of Individuals Covered	182
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,707
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 $7,707
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EMPLOYEE NETWORK INC. (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

XYL7422

Policy instance

Insurance contract or identification number	XYL7422
Number of Individuals Covered	2635
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $31,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

PAI 0009135396

Policy instance

Insurance contract or identification number	PAI 0009135396
Number of Individuals Covered	1629
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $19,265
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $128,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,265
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC.

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0096482

Policy instance

Insurance contract or identification number	0096482
Number of Individuals Covered	1215
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	GROUP UNIVERSAL LIFE
Welfare Benefit Premiums Paid to Carrier	USD $619,683
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

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,862
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

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	23
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $125,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9823022

Policy instance

Insurance contract or identification number	9823022
Number of Individuals Covered	3370
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $241,806
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00500106

Policy instance

Insurance contract or identification number	00500106
Number of Individuals Covered	56
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $437,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

101975767

Policy instance

Insurance contract or identification number	101975767
Number of Individuals Covered	3994
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $18,374
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $390,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,374
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

10197568

Policy instance

Insurance contract or identification number	10197568
Number of Individuals Covered	3163
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $13,287
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $501,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,287
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

HEALTHNOW NEW YORK, INC. (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00416724

Policy instance

Insurance contract or identification number	00416724
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 $66,358
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 $66,358
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFIT CONCEPTS, INC.

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

B&H10027,P12917

Policy instance

Insurance contract or identification number	B&H10027,P12917
Number of Individuals Covered	714
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,717
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,988,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,717
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9748609

Policy instance

Insurance contract or identification number	9748609
Number of Individuals Covered	7
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

9732355

Policy instance

Insurance contract or identification number	9732355
Number of Individuals Covered	661
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $30,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9845439

Policy instance

Insurance contract or identification number	9845439
Number of Individuals Covered	31
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0876001

Policy instance

Insurance contract or identification number	0876001
Number of Individuals Covered	772
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $304,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

32588

Policy instance

Insurance contract or identification number	32588
Number of Individuals Covered	181
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $3,842
Dental 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 $3,842
Insurance broker organization code?	3
Insurance broker name	FJ DICESARE AGENCY, LLC

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

400212664

Policy instance

Insurance contract or identification number	400212664
Number of Individuals Covered	23
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $154
Other welfare benefits provided	VOLUNTARY AD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to Carrier	USD $1,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $154
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )

Policy contract number

10197569

Policy instance

Insurance contract or identification number	10197569
Number of Individuals Covered	304
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $7,458
Other welfare benefits provided	WEEKLY INCOME
Welfare Benefit Premiums Paid to Carrier	USD $137,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,458
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

45251, 500106

Policy instance

Insurance contract or identification number	45251, 500106
Number of Individuals Covered	189
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $92,119
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 $92,119
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9823022

Policy instance

Insurance contract or identification number	9823022
Number of Individuals Covered	2957
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $211,710
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

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	24
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $115,718
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 number

0147603

Policy instance

Insurance contract or identification number	0147603
Number of Individuals Covered	2812
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $9,481
Total amount of fees paid to insurance company	USD $2,100
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $1,351,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,481
Amount paid for insurance broker fees	17
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	18
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $122,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009135406

Policy instance

Insurance contract or identification number	GTP 0009135406
Number of Individuals Covered	1914
Insurance policy start date	2013-11-01
Insurance policy end date	2014-10-31
Total amount of commissions paid to insurance broker	USD $4,733
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $31,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,733
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC.

EMPLOYEE NETWORK INC. (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

XYL7422

Policy instance

Insurance contract or identification number	XYL7422
Number of Individuals Covered	2635
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $31,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00045251

Policy instance

Insurance contract or identification number	00045251
Number of Individuals Covered	27
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $77,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 )

Policy contract number

00518497

Policy instance

Insurance contract or identification number	00518497
Number of Individuals Covered	97
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $225,304
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

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	9
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $137
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $46,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $137
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

PAI 0009135352

Policy instance

Insurance contract or identification number	PAI 0009135352
Number of Individuals Covered	1914
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,113
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $7,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,113
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC.

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9823022

Policy instance

Insurance contract or identification number	9823022
Number of Individuals Covered	2489
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $2,466
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $196,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,466
Insurance broker organization code?	3
Insurance broker name	MARSH GLOBAL CONSUMER

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9845439

Policy instance

Insurance contract or identification number	9845439
Number of Individuals Covered	26
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $-3
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,843
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
Insurance broker organization code?	3
Insurance broker name	MARSH GLOBAL CONSUMER

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

0147603

Policy instance

Insurance contract or identification number	0147603
Number of Individuals Covered	3260
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $6,642
Total amount of fees paid to insurance company	USD $2,048
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $991,130
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,642
Insurance broker organization code?	3
Amount paid for insurance broker fees	2048
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	22
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $201
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $138,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

PAI0009135396

Policy instance

Insurance contract or identification number	PAI0009135396
Number of Individuals Covered	1914
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $13,058
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $87,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,058
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP 0009135406

Policy instance

Insurance contract or identification number	GTP 0009135406
Number of Individuals Covered	1914
Insurance policy start date	2012-11-01
Insurance policy end date	2013-10-31
Total amount of commissions paid to insurance broker	USD $2,136
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,136
Insurance broker organization code?	3
Insurance broker name	MERCER HEALTH & BENEFITS LLC

EMPLOYEE NETWORK INC. (National Association of Insurance Commissioners NAIC id number: 52429 )

Policy contract number

XYL7422

Policy instance

Insurance contract or identification number	XYL7422
Number of Individuals Covered	2635
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $28,982
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 number

147607

Policy instance

Insurance contract or identification number	147607
Number of Individuals Covered	2331
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of fees paid to insurance company	USD $36
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $536,726
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	36
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9845439

Policy instance

Insurance contract or identification number	9845439
Number of Individuals Covered	8
Insurance policy start date	2012-04-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $47
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14
Insurance broker organization code?	3
Insurance broker name	MARSH GLOBAL CONSUMER

STANDARD SECURITY LIFE (National Association of Insurance Commissioners NAIC id number: 69078 )

Policy contract number

9823022

Policy instance

Insurance contract or identification number	9823022
Number of Individuals Covered	1920
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,907
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,907
Insurance broker organization code?	3
Insurance broker name	MARSH GLOBAL CONSUMER

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

Policy contract number

231080

Policy instance

Insurance contract or identification number	231080
Number of Individuals Covered	11
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $173
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $41,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $173
Insurance broker organization code?	3
Insurance broker name	TOWERS WATSON, PA

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

Policy contract number

603645

Policy instance

Insurance contract or identification number	603645
Number of Individuals Covered	25
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,498
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $158,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $641
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

244873

Policy instance

Insurance contract or identification number	244873
Number of Individuals Covered	25
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,974
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $298,712
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,533
Insurance broker organization code?	3
Insurance broker name	TOWERS WATSON PENNSYLVANIA INC

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

PAI0009135396

Policy instance

Insurance contract or identification number	PAI0009135396
Number of Individuals Covered	3005
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,762
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $51,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,762
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )

Policy contract number

GTP0009135406

Policy instance

Insurance contract or identification number	GTP0009135406
Number of Individuals Covered	812
Insurance policy start date	2011-10-31
Insurance policy end date	2012-10-30
Total amount of commissions paid to insurance broker	USD $1,530
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $10,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,530
Insurance broker organization code?	3
Insurance broker name	AON CONSULTING

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

147603

Policy instance

Insurance contract or identification number	147603
Number of Individuals Covered	2710
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $6,025
Total amount of fees paid to insurance company	USD $747
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $997,199
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,266
Amount paid for insurance broker fees	36
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

CARE PLUS SOLUTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 54612 )

Policy contract number

8312

Policy instance

Insurance contract or identification number	8312
Number of Individuals Covered	3800
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Other welfare benefits provided	EAP
Welfare Benefit Premiums Paid to Carrier	USD $42,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	XYLEM INC.
Employer identification number (EIN):	452080495
NAIC Classification:	333200